Foot complications such as amputation and foot ulceration are common consequences of diabetic neuropathy and peripheral arterial disease (PAD). These complications have been identified as major causes of morbidity and disability in people with diabetes. “Early recognition and management of risk factors for foot complications is critical,” says Paul J. Kim, DPM, MS. “Efforts to identify and treat these complications early in the disease course can prevent or delay adverse outcomes.”
The American Diabetes Association notes that the risk of foot ulcers or amputations is increased in people who have various risk factors. “Neuropathy, peripheral vascular disease, and foot deformities are the most important risk factors for foot complications,” says Dr. Kim. “Poor blood glucose control is the trigger for the cascade for these complications.”
A range of tests might be useful when identifying patients at risk for foot ulceration, but this has created some confusion among practitioners as to which screening tests should be adopted in clinical practice. To clear this confusion, the American Diabetes Association has issued several recommendations on what should be included in comprehensive foot exams for adults with diabetes in its annual Standards of Medical Care in Diabetes (Table 1). All adults with diabetes are recommended to undergo a comprehensive foot examination to identify high-risk conditions at least once a year. During these exams, clinicians should ask patients about their history of previous foot ulceration or amputation, neuropathic or peripheral vascular symptoms, impaired vision, tobacco use, and foot care practices. A general inspection of skin integrity and musculoskeletal deformities should also be performed.
Neurologic exams are designed to identify loss of protective sensation (LOPS) rather than early neuropathy. Clinical examinations to identify LOPS are simple and require no expensive equipment. The American Diabetes Association notes that any of five simple clinical tests can be used when diagnosing LOPS in diabetic feet. Ideally, two of these tests should be regularly performed during screening exams, most commonly the 10-g monofilament and one additional test.
During initial screenings for PAD, clinicians are recommended to ascertain a history for claudication and assess pedal pulses. A diagnostic ankle brachial index (ABI) should be performed in any patient with symptoms of PAD. PAD is increasing in prevalence among patients with diabetes, and many of these individuals are asymptomatic. As such, a screening ABI should be performed in patients older than age 50. An ABI should also be
considered in patients under the age of 50 if they have other PAD risk factors. The American Diabetes Association recommends that patients be referred to specialists if they have significant symptoms or a positive ABI for further vascular assessment and treatment.
“Patient education on diabetes and associated foot conditions is a key component to optimizing care,” says Dr. Kim (Table 2). “Patients need to be educated about their risk factors and how to appropriately manage them. At-risk individuals must understand the implications of their symptoms, the importance of daily foot monitoring and care, and how to select the most appropriate footwear.”
“Patient education on diabetes and associated foot conditions
is a key component to optimizing care.”
The American Diabetes Association recommends that patients with LOPS be educated on the potential impact of these issues. “Patients’ physical ability to conduct proper foot surveillance and care should be assessed,” Dr. Kim adds. Those with visual difficulties, physical constraints that prevent movement, or cognitive problems may need other people in their life, such as family members or friends, to assist in care.
Patients with diabetes who have neuropathy or evidence of increased plantar pressure may be adequately managed with well-fitted walking shoes or athletic shoes that cushion the feet and redistribute pressure. Calluses can be debrided with a scalpel by foot care specialists or other health professionals with experience and training in foot care. “People with bony deformities—such as hammertoes, prominent metatarsal heads, and bunions—may need special shoes that can further protect them from foot complications,” says Dr. Kim. “People with extreme bony deformities who cannot be accommodated with commercial therapeutic footwear may need custom-molded shoes.”
Typically, diabetic foot wounds without evidence of soft tissue or bone infection do not require antibiotic therapy, but empiric antibiotic therapy can be narrowly targeted for many acutely infected patients. “Patients at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections will need broader-spectrum regimens and should be referred to specialized care centers,” says Dr. Kim. “To optimize care, a multidisciplinary team approach is needed. Consultations with podiatrists, orthopedic or vascular surgeons, and rehabilitation specialists can be of great benefit when managing patients with diabetes.”
Readings & Resources (click to view)
American Diabetes Association. Standards of Medical Care in Diabetes—2014. Diabetes Care. 2014;37:S14-S80.
Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54:132-173. Available at: http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/2012%20Diabetic%20Foot%20Infections%20Guideline.pdf.
Boulton AJ, Armstrong DG, Albert SF, et al. Comprehensive foot examination and risk assessment: a report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care. 2008;31:1679-1685.
American Diabetes Association. Peripheral arterial disease in people with diabetes. Diabetes Care. 2003;26:3333-3341.
Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005; 293:217-228.
Frykberg RG, Zgonis T, Armstrong DG, et al. Diabetic foot disorders. A clinical practice guideline (2006 revision). J Foot Ankle Surg. 2006;45:S1-S66.