Diabetic foot

Posted by e-Medical PPT
Foot ulceration – 'diabetic foot' – is the commonest reason for people with diabetes to be admitted to hospital in the UK. It is a result of nerve damage (neuropathy) and lack of blood supply (ischaemia). If an ulcer becomes infected and gangrenous this can necessitate amputation.

Ischaemic or Neuropathic Pain
Ischaemic Pain
Persistent pain
Worse on elevation
Relieved by dependency
Pain in calf on exercise (claudication) relieved by rest

Neuropathic Pain
Burning pains
Contact pains due to sheets or other touch
Sharp short shooting pains
Pain relieved by cold
Pain worse during rest

Check for Neuropathy
The method of choice is the 10gm monofilament applied perpendicular to the foot and pressure applied until it bends
Sites to test:
Apex of first, third, and fifth toes and the ball of the foot (MTP joints) of the same toes, dorsum of foot and heel
Vibration sense tested on dorsum of first toe and a site further proximal such as the lateral malleolus using a 128-Hz tuning fork
When testing get the person to close their eyes
Repeat the test three times at each site
One of those three tests should be a non test where the foot is not touched
This is to ascertain whether the person being tested is telling you what they “feel” you want to hear

Check the Foot Pulses
If you palpate either of these pulses it is unlikely there is any significant ischaemia in the foot
If both pulses are not palpable then check the popliteal and femoral pulses
ABPI (Ankle Brachial Pressure Index) can be undertaken but calcification of arteries in Diabetes can lead to falsely high ABPI readings so toe pressures could be undertaken (TBPI)

Neuropathy
Diabetic Peripheral Neuropathy is the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes, after exclusion of other causes e.g. Multiple Sclerosis (Boulton et al 1998)

This can be sub divided into
Motor Neuropathy
Painful Neuropathy
Autonomic Neuropathy
Sensory Neuropathy
Charcot Neuroarthropathy

Diabetic amyotrophy
This is a rare and unusual manifestation which results in poor motor control of the leg muscles usually bilateral leading to muscle weakness and muscle wasting
Usually affects the quadriceps (anterior thigh)
May also affect hamstrings (posterior thigh)
Not always associated with sensory loss..

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