Diabetic Foot

Uncontrolled diabetes contributes to the development of neuropathy and peripheral arterial disease by complex metabolic pathways. Loss of sensation is caused by peripheral neuropathy, and peripheral arterial disease or a combination of these may lead to foot ulcers.

A diabetic foot ulcer is an open sore or wound that occurs in approximately 15 percent of patients with diabetes and is commonly located on the bottom of the foot. Worldwide, every 20 seconds a limb is lost due to diabetes. People with diabetes are 10 to 20 times more likely to experience an amputation compared to those who do not have diabetes.

A thorough foot examination is important to detect the disease early. Screening for peripheral neuropathy and peripheral arterial disease can help identify patients at risk of foot ulcers. A history of ulcers or amputations and poor glycaemic control increase the risk.

Feet must be examined at each follow-up visit for active diseases such as ulceration or gangrene. Look for lesions such as fungal infection, cracks and skin fissures, deformed nails, macerated web spaces (especially between the toes), calluses, and deformities such as hammer toes, claw toes, and pes cavus (high arch foot), which increase the risk of ulceration. Feel the temperature of the feet with the dorsum of your hand.

A cold foot might suggest ischaemia, and increased warmth with redness and swelling might suggest inflammation such as acute Charcot foot or cellulitis. Foot deformities like hallux valgus, claw toe or hammertoe, osseous prominences, loss of plantar arches, range of motion, and gait abnormalities should also be noted.

The neurological examination includes testing for sensory, motor, and autonomic neuropathy including evaluation of the Achilles reflex (ankle jerk reflex). A simple bedside evaluation including 10 gm Semmes-Weinstein monofilament, vibration testing with 128 Hz tuning fork or vibration perception threshold (VPT) > 25 (by Vibrotherm), temperature perception, and ankle reflex is useful for assessing peripheral diabetic neuropathy. In patients with faint or nonpalpable pedal pulses, ABI has proven to be a reliable and simple examination to evaluate PAD in outpatient settings. Abnormal ABI values may indicate the need for more detailed vascular studies, such as peripheral arterial duplex Doppler.

Foot care education among diabetic patients plays an inevitable role in the:

• prevention of foot ulcers, hence constantly checking your feet
• Proper foot hygiene
• wearing right footwear
• quitting smoking and timely check-ups will help prevent the development of foot ulcers.