Diabetic feet need extra care. Even small foot problems can become serious for people with diabetes. Always check with your doctor before treating a foot issue at home.
An early diagnosis of diabetes-induced foot ulceration is crucial to prevent the condition from escalating any further. A report released in 2008 by the American Diabetes Association recommends a set of examinations that can effectively diagnose the condition. Firstly, healthcare providers should take into consideration the patient’s medical history and especially check for any previous instances of amputation or ulceration. The evaluation should also take into account any history or symptoms indicative of peripheral vascular disease. Additionally, a detailed inquiry must be made concerning other diabetes-related complications such as vision defects and kidney problems, particularly dialysis, or if the patient had a kidney transplant done recently. Finally, the patient should be asked about their cigarette consumption, since smoking can provoke the onset of, and worsen the impact of, neuropathic and vascular diseases. A detailed assessment of all these factors will enable healthcare providers to effectively gauge the risk of foot ulceration in the patient.
Visual Inspection
After a detailed evaluation of the patient’s medical history, a barefoot visual inspection should be performed. This should be done in a well-lit room. The examination should start with seeing if the patient is wearing the appropriate shoes, as otherwise it could also be a cause for ulceration. When ill-fitting or inappropriate shoes are worn over a period of time, bunions and other foot deformities can occur, leading to nerve damage and loss of sensation in the feet. While conducting the inspection, it is important to look between the toes to check for any telltale signs of infection or ulceration. Any nail abnormalities or calluses should be considered as red flags. Also, any variation in temperature between the feet may indicate an underlying vascular disease.
Red Flags to Look for During Inspection
Firstly, the foot should be examined for any sign of deformity. These deformities are caused by innervations or dysfunction of the foot muscles, and are brought on as a result of extreme nerve damage. For instance, a hammertoe can form as a result of imbalance in the ligaments and muscles in the toes. As a result of muscular imbalance, there is a lot of pressure exerted on the tendons and connective joints of the toes. The toe gradually loses its flexibility, causing the middle joint to curl up in the shape of a hammer. Charcot’s joint, or diabetic arthropathy, is one of the most common conditions that manifests in people suffering from diabetes-induced neuropathy or nerve damage. The earliest symptoms of this condition include redness and increased swelling as a result of water retention in the tissues around the affected joint, as well as warmth around the ankle and foot of the patient. If the condition is not recognized and treated at that stage, the symptoms may worsen. There is an increased risk for fractures or dislocations of the joints in the affected area. During the examination, the medical practitioner should look for any sign of this condition. At this point it is still in the first stage, and can be treated. Even at a somewhat later stage, its progression can be slowed by proper care.
Other signs and symptoms of established infection include intense pain as well as tenderness in the affected area, discharge of pus, and a malodorous smell. The patient should also be asked about night sweats, weight loss, nausea, cold sweats, and fever. Mental imbalance may also occur in advanced cases.
Physical Evaluation
A visual inspection should be followed up by a thorough physical examination. This would include assessing the patient’s BMI, vital statistics, and overall well-being. If the patient exhibits any or all of the symptoms and signs that follow—high fever, elevated heart rate, extreme tension, nervousness, or rapid breathing— it is evident that severe infection has set in. However, it is also possible that severe neuropathy may impair the patient’s neuro-inflammatory response so as to inhibit the appearance of any of these signs. There is documented evidence that almost 90 percent of patients who were admitted for bone-related diseases caused by diabetes exhibited no external signs of infection. In such a scenario, the following tests have proved to be effective in diagnosing neuropathy:
Semmes-Weinstein Monofilament Exam
The extent of nerve damage in the patient can be gauged with the Semmes-Weinstein monofilament exam. During this procedure, 10g of force is exerted on the patient’s skin for a second using the Semmes-Weinstein 5.07 monofilament nylon wire. A patient who cannot feel any sensation with this test is considered to have severe neuropathy.
128 C Tuning Fork The 128 C tuning fork is used to evaluate the patient’s vibratory sensation. The fork is struck near the ankle and the joints of the patient’s toes. If the patient is unable to sense any vibration near the toes but can sense it near the ankles, a diagnosis of neuropathy is established.
All secondary signs of infection must be evaluated thoroughly.
These include the production of discharge, and the breakdown or delayed healing of wounds. The evaluator must document wounds with a detailed description, such as the color and length of the wound, the consistency of the discharge, and the nature of the wound base.
The legs should be elevated for about 5 minutes to confirm the nature of the redness or swelling in the feet. If bone material is visible at the base of an ulcer, the presence of osteomyelitis is confirmed.
Vascular Assessment
A thorough evaluation of the patient’s vascular system is critical to determine if the patient is prone to ulceration caused by ischemia. Firstly, the two major arteries in the lower limbs, namely, the posterior tibial artery and the dorsalis pedis, should be palpated to determine the presence or absence of a normal pulse in either or both of them. Some of the physical symptoms of ischemia include pain in the legs and feet as a result of poor blood flow, hair loss, and the presence of skin patches that are thin, pale, and cool to the touch.
Measurement of the ankle-brachial index (the ratio of the blood pressure at the ankle to the blood pressure in the arm) is another effective method to determine if the patient has a vascular disease. The measurements are taken using a handheld instrument called a Doppler probe, with the patient in supine position, and the ratio is calculated. Any ratio that is below 0.91 is indicative of an obstruction caused by ischemia. These assessments should be followed up with vascular imaging to confirm that the patient has ischemia, and to determine how far the disease has progressed.
-- ON of 63 -- FUN FACT The 52 bones in your feet make up one quarter of all the bones in your body. When they are out of alignment, so is the rest of your body.
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