DM - FOOT EVALUATION IN THE PRIMARY CARE SETTING

1. DM - FOOT EVALUATION IN THE PRIMARY CARE SETTING Bernadette Pendergraph, Gloria Sanchez, MDs Cindy Mayeda, RN Department of Family Medicine, Harbor-UCLA “An ounce of prevention is worth a pound of cure.”– Benjamin Franklin

2. Learning Objectives • Medical Knowledge a. Perform Comprehensive DM Foot Exam b. Implement ADA DM Foot Guidelines c. Classify DM Foot Ulcers Accurately d. List indications for imaging • Patient Care a. Offloading Devices for DM Ulcers b. Utilize consultants in timely fashion No conflicts of interest

3. Learning Objectives • System Based Practice a. Utilize resources for patients b. Expedite pt work up & tx PRN • Interpersonal & Communication Skills a. Teach pts DM foot care & precautions b. Collaborate with HC team to examine & treat pts • Professionalism a. Take “ownership” of DM foot ulcer

4. IMPORTANCE OF FOOT EXAMS • National Hospital Discharge survey 1996 86,000 with DM under went > 1 amputation • DM leading cause of amputation in lower extremities • > 50% preventable • Triad: neuropathy, deformity, trauma • Absence of nerve and vascular complaints is not protective • Incidence of: • Foot ulcers up to 25% lifetime risk, annual risk 2% • ~50% infected • 14-24% amputation • Lower extremity amputation • 50% in same/opposite extremity in 5 yrs. • Mortality all cause at 5 yr 39-68%

5. IMPORTANCE OF FOOT EXAMS • Healthy People 2020 goals • Increase # of persons receiving at least an annual foot exam • Decrease amputations related to DM • Ethnic risk for amputation per 10,000 persons with DM • African-Americans 95.3 • Hispanic 44.4 • Caucasians 56

6. IMPORTANCE OF FOOT EXAMS • % amputations related to DM • Hispanics 82.7 • African-Americans 61.6 • Caucasians 56.8 • Foot exam frequency • By patient • Daily 52% • Never 22% • By provider • Type 1 66% • Type 2 52%

7. COST OF DM FOOT DISEASE • Amputations > $1.1 billion • Ulcer in male 40-65 y.o. $28,000 over 2 yr

8. RISK FACTORS FOR AMPUTATION • Arterial insufficiency: DM > 10 yrs, Tobacco use • Disease control: high FBS, high A1c, duration = two fold increase • Sex: male • Eng Organ Damage: • Retinopathy • Nephropathy • Cardiovascular disease • Peripheral neuropathy: absent Achilles reflex, decreased vibratory sensation = 2 x likely in amputees • Abnormal gait 15x more likely to injure • Abnormal monofilament exam 60% develoed ulcers, 21% amputations over 32 months

9. RISK FACTORS FOR AMPUTATION • Abnormal foot anatomy • Nail – Onycholysis, Ingrown • Skin – Xerosis, Corn, Callus, Hair loss • Bone – Halluxvalgus, hammer toes, prominent metatarsal heads, Charcot foot • Previous ulcer or amputations • Loss of monofilament perception – 18 fold increase risk of ulcer

10. PRECIPITATING EVENTS FOR AMPUTATION • Injury from new shoes • Improper toe nail trimming • Accidental wounds • Thermal injury • 1/3 of injuries self induced in PVD

11. ADA GUIDELINES • Everyone with DM gets a foot exam • Starts at diagnosis • Frequency: At least annual – stratify high vs low risk • Visual inspection every visit if neuropathy • Prerequisite history • Previous ulceration, amputation, Charcot joint, vascular surgery, angioplasty, tobacco use • Symptoms of claudication or neuropathy • DM complications: renal, visual

12. ADA GUIDELINESFOR FOOT CARE • Foot exam components • Visual inspection: dermatologic, musculoskeletal, shoe • Neurological assessment: 10g Monofilament + 1 of the following: • Vibration • Pinprick • Ankle reflexes • VPT • Vascular: Pulses, consider ABI

13. DERMATOLOGIC INSPECTION • Nails • Shape/length • Ingrown, paronychia • Onycholysis • Skin • Xerosis • Callus/Corn/Ulcer • Temperature

14. MUSCULOSKELETAL ASSESSMENT • Deformities • Toe deformities-claw , hammer • Bunions • Charcot foot

15. SHOE EVALUATION • Look at the patient’s shoes (Are these shoes appropriate for these feet?) • Type of material? • Good: canvas, suede, leather, elastic • Bad: plastic • Any foreign objects? • Depth appropriate? • Width appropriate? • Size? • How old?

16. NEUROLOGIC ASSESSMENT • Peripheral neuropathy most common cause of DM foot ulceration • Identify loss of protective sensation (LOPS) • 10 g monofilament • 128 Hz turning fork: vibratory sensation-tip of great toe bilaterally • Pinprick: disposable pin proximal to nail of great toe • Ankle reflexes • Vibration perception threshold testing: mean of 3 readings; VPT > 25V

17. MONOFILAMENT TESTING • Patient should close the eyes • Check patient on proximal site to demonstrate • Instruct the patient to tell you when he feels the monofilament • Push the monofilament until it bends, then hold for 1-2 seconds • Lift the monofilament from skin • Retest the area where the patient did not feel the monofilament (Avoid callus) • Mark the areas of the foot using a plus sign (+) if they can feel the monofilament and a minus sign (-) if they cannot

18. VASCULAR ASSESSMENT • PAD is a component cause in 1/3 of ulcers • Risk factor for recurrent wound • Palpate dorsalispedis and posterior tibialis • If pulses are absent or symptoms of PAD, do ABI • DM > 50 yo • DM < 50 with multiple PAD risk factors

19. ABI Readings • Abnormal >1.2 (medial calcinosis) • Normal 0.9-1.2 • Moderate Vascular Dz 0.4-0.8 • Severe Vascular Dz <0.4

20. TOE PRESSURE TESTING (TBI) • Consider doing if ABI > 1.2 • Cut off are different than ABI • TBI > 0.5 or > 70 mm Hg = normal • TBI < 0.2 or < 30mm Hg = severely ischemic

21. RISK CLASSIFICATION

22. FOOT CONDITIONS TO WATCH OUT FOR • Diabetic foot infections: inframalleolar infection in a person with DM • Acute: Predominantly g+ cocci • Clindamycin • Keflex • Bactrim • Augmentin • Chronic: g-rods • 2nd generation cephalosporin • Linezolid • Daptomycin

23. DIABETIC FOOT INFECTIONS • Ischemia: obligate anaerobes • Vascular evaluation • Fluoroquinolone + clindamycin • Imipenem • Vancomycin + Ceftazidime + metronidazole

25. ULCERS • Venous stasis ulcer • Medial malleolar area • Irregular borders • Red-brown staining • Lower extremity edema/varicose veins • Arterial insufficiency ulcer • Tip of the toe • Punched out (clear demarcation) • Pale, dry base without edema

26. WAGNER ULCER CLASSIFICATION • Grade 0 = no ulcer in high risk foot • Grade 1 = ulcer involving full skin thickness • Grade 2 = ulcer to ligament and muscle • Grade 3 = ulcer with cellulitis/abscess • Grade 4 = localized gangrene • Grade 5 = extensive gangrene involving whole foot

28. ULCER TREATMENT • Patients should never walk out in the same shoe wear they walked in… • Offload ulcer • Modify shoe insert – cut out area under ulcer • Healing boot • Total contact cast • Assess vascularity • Wound care • Inciting event – shoe, foreign body = xray • Debridement • Assess if Infected • Close follow-up

29. FOOT CONDITIONS • Charcot foot • Neuropathic joint – progressive destruction of bone and soft tissues at weight bearing joints • Rocker bottom foot with continued ambulation • Incidence in DM: 0.15-2.5% • Recurrence 5% • Bilateral disease 10% • Men = Women

31. PATHOGENESIS OF CHARCOT

32. STAGING

33. WHICH ONE IS CHARCOT FOOT?

34. NORMAL FOOT

35. CHARCOT FOOT • Acute • Inflammatory: swelling, increased temperature (3-7°F), redness, bony resorption • Intact skin and pulses • Insensate foot • Treatment • Immobilization: total contact cast • Reduce stress: non-weight bearing • r/o infection • Chronic • Protection: orthotics, surgery

36. TREATMENT OVERVIEW

37. OTHER ORTHOSIS • Charcot foot • AFO: offload bottom of foot and reduce ankle motion • Total contact cast: transfer weight away from foot • Pneumatic walker brace

38. OTHER ORTHOSIS • Charcot foot • AFO: offload bottom of foot and reduce ankle motion • Total contact cast: transfer weight away from foot • Toe amputations • Toe filler • Forefoot amputations: custom shoes

39. Achilles lengthening • Transmetatarsal amputation

40. SHOE PRESCRIPTIONS • Healing shoes: post op or heat molded shoes • Depth in-lay: toe deformities, prescription inserts • Extra wide: bunions • Rocker sole: reduce pressure on metatarsal heads; hallux rigidis • Custom molded: severe feet deformities

41. SHOE PRESCRIPTIONS • Medicare covers custom shoes for persons with DM, in a comprehensive DM care program and one of the following: • H/o amputation • H/o ulcer • H/o preulcerative callus • Peripheral neuropathy with callus • Poor circulation • Foot deformity • Products for the year • One pair of depth shoes with 3 inserts • One pair of custom-molded shoes/inserts with 2 inserts

42. FOOT CARE INSTRUCTIONS • Good sugar control • Daily visual exam • Moisturize your feet • Appropriate shoe wear – never barefoot, no open toe box • Firm heel counters and uppers – to prevent excessive motion and rolling • A firm and wide outsole – to provide a stable base for the foot • An extra-depth construction with a removable inlay – to provide added cushion; allow room for a custom foot orthosis

43. HOW TO DEAL WITH PROBLEMS • Thermal injury • Shoe color (8-13°) • Bony abnormalities • Mild deformities: Appropriate depth and width • Athletic shoes • Soft insoles: plastazote/urethrane viscoelastic • Laces or Velco strap • Severe deformities or amputation: Shoe prescription • Relieve excessive pressure • Decrease shock, sheer pressures • Accommodate, stabilize, and support deformities

44. Medicare pays 80% of what is allowed Depth shoes $126 Custom molded shoes $378 Inserts $64

45. RISK FACTORS FOR FOOT ULCER • Poor glycemic control • Visual impairment • Previous foot ulcer/amputation • Peripheral neuropathy • PAD • Foot deformity • DM nephropathy • Cigarette smoking

46. High risk: amputation, ulcer • Elevated A1c doubles risk of amputation