Phys Di - Diabetic Foot Flashcards
Define neuropathy
presence of symptoms and /or signs of peripheral nerve dysfunction in people with diabetes after the exclusion of other causes
Which diabetic neuropathy is MC?
chronic DSPN (distal symmetrical polyneuropathy) -accounts for 75% of diabetic neuropathies
What is the pathogenesis of neuropathy?
oxidative and inflammatory stress, in the context of metabolic dysfunction, damage nerve cells
Incidence and prevalence of DSPN
- occurs in at least 20% of people with T1DM after 20 years of disease duration
- at least 10-15% of newly diagnosed patients with T2DM have DSPN
- after 10 years of T2DM disease duration, 50% have DSPN
- DSPN – small-fiber neuropathy subtype may be present in 10-30% of people with prediabetes or metabolic syndrome.
DSPN is associated with…
degree of glycemic control, height, smoking, blood pressure, weight, and lipid measure
Why is DSPN important to comorbidities of the foot?
-DSPN is an important cause of foot ulceration
-DSPN is a prerequisite for Charcot foot neuroarthropathy (CN)
-foot ulceration and CN are late complications of DSPN
-these complications drive amputation risk
-they are predictors of mortality
DSPN is a major contributor to falls and fractures
What is Charcot foot?
- loss of arch
- movement of toes
DSPN screening - type 2 vs type 1 DM
All patients should be assessed for DSPN starting at diagnosis of T2DM and 5 years after the diagnosis of T1DM and at least annually thereafter
Should you screen DSPN in prediabetes?
Yes, consider screening patients with prediabetes who have symptoms of peripheral neuropathy
Symptoms of DSPN
-vary according to the class of sensory fibers involved.
MC early symptoms are due to small fiber disease: pain, dysesthesias (unpleasant sensations of burning)
Neuropathic pain:
- Burning, lancinating, tingling, shooting (electric shock-like)
- Usually worse at night
- Exaggerated response to painful stimuli and pan evoked by contact
DSPN of large myelinated nerve fibers
-function, sx, exam
- function: pressure and balance
- Sx: numbness, tingling, poor balance
Exam:
- Ankle reflexes: reduced/absent
- Vibration perception: reduced/absent
- 10-g monofilament: reduced/absent
- Proprioception: reduced/absent
Symptoms related to large fiber involvement in DSPN
Numbness
-May complain that feet feel like they are wrapped in wool or they are waling on thick socks
Tingling without pain
Loss of protective sensation
- Loss of the “gift of pain”
- A risk factor for diabetic foot ulceration
DSPN of small myelinated nerve fibers
-function, sx, exam
- Function: nociception, protective sensation
- Sx: pain experienced as burning, electric shock, stabbing
Exam:
- thermal (cold/hot) discrimination: reduced/absent
- pinprick sensation: reduced/absent
Describe the Pin Prick test
- Disposable pin is applied proximal (skin just below) the big toenail enough to deform the skin
- Normal exam would be to distinguish sharp/not sharp
Describe the thermal test
- Can the patient distinguish between cold and warm?
- Simple approach: use tuning fork with beaker of ice/warm water
- Normal result would be the patient can distinguish hot from cold
How does loss of protective sensation (LOPS) contribute to complications?
Loss of protective sensation (LOPS) can render patients unable to recognize damage to their lower extremities, thus creating a cycle of tissue damage and other foot complications.
Is the diabetic foot exam performed often enough??
- Strong evidence suggests that consistent provision of foot-care services and preventive care can reduce amputations among patients with diabetes.
- However, routine foot examination and rapid risk stratification is often difficult to incorporate into busy primary care settings.
**Data suggest that the diabetic foot is adequately evaluated only 12% to 20% of the time
Name the 3 components of the ADA Comprehensive Foot Examination and Risk Assessment
- Taking a patient history,
- Performing a physical exam, and
- Providing patient education.
What patient history should you ask?
- previous leg/foot ulcer or lower limb amputation/surgery
- prior angioplasty, stent, or leg bypass surgery?
- foot wound requiring more than 3 weeks to heal?
- smoking or nicotine use?
- diabetes (if yes, what are current control measures)?
What should you ask about current patient symptoms?
- burning or tingling in legs or feet?
- leg or foot pain with activity or at rest?
- changes in skin color or skin lesions?
- loss of LE sensation?
*has the patient established regular podiatric care?
What are the 4 components of diabetic foot exam?
- Dermatologic,
- Neurologic,
- Musculoskeletal
- Vascular
What to look for on derm exam?
- does patient have discolored, ingrown, or elongated toenails?
- are there signs of fungal infection?
- does the patient has discolored and/or hypertrophic skin lesions, calluses, or corns?
- does the patient have open wounds or fissures?
- does the patient have interdigital maceration?
What to look for on neurologic exam?
is the patient responsive to the Ipswitch Touch Test?
What to look for on musculoskeletal exam?
- does the patient have full range of motion of the joints?
- does the patient have obvious deformities? If yes, for how long?
- is the midfoot hot, red, or inflamed?
What to look for on vascular exam?
- is the hair growth on the foot dorsum or lower limb decreased?
- are the dorsalis pedis and posterior tibial pulses palpable?
- is there a temperature difference between the calves and feet or between the left and right foot?
What foot deformities do you look for?
- Prominent metatarsal heads
- Claw or hammer toes
- Rocker bottom foot deformity
- Bunions
- Prior amputation
What 2 arteries should you check for vascular changes?
Dorsalis pedis A and posterior tibial A
How do you assess biomechanical/mechanical changes?
- *Perform plantar flexion/dorsiflexion of ankles and great toes bilaterally
- Neuromuscular disturbances, such as a reduction in the strength of dorsiflexion and plantar flexion, may indicate a complicated neurologic compromise.
- Note foot deformities
Patient education: what are the recommendations for daily foot care?
- visually examine both feet, including soles and between toes
- keep feet dry by regularly changing shoes and socks; dry feet after bath or exercise
- report any new lesions, discolorations, or swelling to a health care professional
Patient education: what are the recommendations for shoes?
- educate patient on risks of walking bare foot, even when indoors
- recommend appropriate footwear and advise against shoes that re too small, tight, or rub against a particular area of the foot
- suggest yearly replacement of shoes - more frequently if they exhibit high wear.
Patient education: what are the recommendations for overall health risk management?
- recommend smoking cessation (if applicable)
- recommend appropriate glycemic control
