1. The Diabetic
Foot in
Primary Care
Andre Sookdar
Class of 2013

2. Objectives
• Epidemiology
• Clinical Presentation
• Prevention
• Management
• Insulin Initiation

3. Definition
WHO
• The foot of a Diabetic Patient that has the
potential risk of pathologic consequences
including infection, ulceration and/or
destruction of deep tissues associated with
neurologic abnormalities, various degrees
of peripheral vascular disease and/or
metabolic complications of diabetes in the
lower limb.

4. Definition
Any foot pathology that results from Diabetes
or its long-term complications
(Boulton. 2002). Diabetes, 30 : 36, 2002

5. Epidemiology
• WHO estimates approx 60,000 persons in
T&T were diabetic in 2000
• Projected increase to 125,000 by 2030
• MOH estimates 1 in 5 adults are diabetic;
as much as 175,000
• 450 children with Type 1 DM
• More prevalent in the East Indian
community, but 33% of African attendees
of the public health services are both
Diabetic and Hypertensive
• Cause for about 25% Hospital Admissions

6. Epidemiology
• More than 450 non traumatic lower limb
amputations in 2010
• DM foot problems account for 14% of
admissions, 29% of bed occupancy
• 50% of persons who had lower limb
amputations develop depression; 20% die
within 2 years
• V Naraynsingh et al - 822 clinic patients
who had amputations between 2000-2004
reviewed; 515 (80%) due to DM

7. Risk Factors
• Age
• Duration of DM
>10yrs
• Gender M>W
• Poor glycemic
control
• Social situation and
support
• Obesity
• Alcohol
• Smoking
• Depression or
Mental illness
• Previous Ulcer
• Trauma
• Retinopathy
• Nephropathy
• Willful self neglect

8. Pathology
Neuropathy
• Sensory: lack of sensation  Repetitive
Trauma
• Motor: Changes in Foot anatomy 
Pressure Points
• Autonomic: Lack of sweat  Dry Skin
Distended veins  AV Shunting
Osteoarthropathy: Changes in foot structure
Charcot’s foot

9. Pathology
Callus: separates dermis  Ulcer Formation
Infection: Disruption of skin barrier, warmth
and moisture
Peripheral Vascular Disease: reduced blood
flow  decreased O2 supply  increased
risk of infection and poor healing

11. Diabetic Foot Assessment
• History
• Examination
• Investigations
• Risk Assessment

12. History
General Hx
• Medical Hx
• Surgical Hx
• Drug Hx
• Allergies
Foot History
• PC for Foot
• Neuropathic vs
Ischaemic Pain
• Daily activities &
use
• Foot Care
• Callus Formation
• Deformities
• Prev Surgeries
• Skin & Nail

14. Ulcer History
• Site, size, shape, duration, odor, type
• Precipitating event or Trauma
• Recurrence
• Infection
• Hospitalization & Treatment
• Wound Care
• Patient Compliance
• Previous Foot Trauma or Surgery
• ? Charcot’s Foot

15. Examination
• General Examination
• Inspection
• Palpation
• Neurological Assessment
• Footwear Assessment

16. General Examination
• Cardiovascular
• Respiratory
• Abdominal
• Eyes : Visual Acuity, Fundi
• Systemic Signs of Infection

17. Inspection
• Skin: dry, fissures, hair loss, dilated veins,
ulcers, bullae, fungal infections
Necrobiosis Lipoidica Diabeticorum,
Diabetic Dermopathy

18. Inspection
• Corns and Calluses
• Nails: Thickened or Atrophic, Ingrown
,Colour of nail bed, Discharge, Fungal
infections
• Oedema: poor fitting shoes, impedes
healing
Indicator of CV, Renal status, venous
insufficiency, infection, Gout, Trauma,
DVT, lymphoedema and many more

21. Inspection
• Deformity: abnormal pressure distribution
• Pes Cavus
• Fibrofatty padding depletion
• Hammer toes
• Claw Toes
• Hallux Valgus
• Charcot Foot
• Iatrogenic

24. Inspection
• Colour
• Red – Cellulitis, Critical ischaemia,
Osteomyelitis, Gout, Burn
• Blue – Cardiac Failure, Venous insuffiency
• Black – Necrosis, Ischaemia, Emboli,
Bruise, Melanoma, Henna, Dye

26. Palpation
• Pulses – Dorsalis Pedis, Posterior Tibial
Presence of either makes ischaemia
unlikely
If neither are present  Doppler
Dependent Rubor  PVD
• Temperature
Hot  Infection, Charcot, Bony or Soft
tissue Trauma, Gout, DVT
Cold  Ischaemia (acute and chronic),
Cardiac Failure
• Oedema
• Crepitus  Gas Gangrene

28. Neurologic Assessment
• Motor Neuropathy
• Classically, high medial longitudinal arch
 prominent metatarsal heads and
pressure points over the plantar forefoot
• Assess dorsiflexion for foot drop (common
peroneal nerve palsy)
• Autonomic Neuropathy
• Dry skin, fissures, distended veins
• Stocking distribution

29. Neurologic Assessment
• Sensory Neuropathy
• Monofilament test buckles @10g
• Vibration 128 Hz tuning fork
• Temperature
• Light Touch
• Pain
• Eyes closed, non-touch

31. Footwear Assessment
• Examine both
shoes and socks
• Length, breadth,
depth
• Heel height
• Lace/strap vs slip-
on
• Shoe lining
• Foreign bodies
• Wear and tear
• Snug fit, loose or
tight?
• What other shoes
does the patient
wear?
• Sock size, seams,
tightness, holes,
absorbency?
• Cardboard cutout
test

32. Investigations
• Laboratory
• Radiological
• Vascular
• Neurological
• Foot Pressures

33. Laboratory
• CBC
• RFT
• LFT
• RBS, HbA1C
• Lipid Profile
• CRP
• Wound Cultures
• Blood and Urine Cultures

34. Radiological
• Plain Films
• Osteomyelitis
• Fractures
• Dislocations
• Charcot foot
• Foreign Body
• Gas
• CT
• Technetium bone scan – early detection
• MRI – Soft tissue

36. Vascular
• Doppler; pulses, Ankle Brachial Pressure
Index
• <1  ischaemia
• Patients with arterial calcification 
elevated systolic pressure, hence the
pressure index may be >1 in spite of
ischaemia
• Investigate Popliteal and Femoral Arteries

37. Neurological
• Neurothesiometer
• Varying vibratory stimulus

38. Foot Pressures
• Plantar pressure measurement devices
• Ink and paper

40. Classification
• University of Texas Wound Classification
System of Diabetic Foot Ulcers
• Wagner
• Edmonds

41. Edmonds Classification
• Based on natural progression
• Stage 1: Normal or Low Risk Foot
• Stage 2: High-Risk Foot
• Stage 3: Ulcerated Foot
• Stage 4: Infected Foot
• Stage 5: Necrotic Foot
• Stage 6: Unsalvageable Foot

42. Edmonds Classification
• Stage 1 – The foot is not at risk
Sensation and pulses good
No deformities, calluses or swelling
• Stage 2 – One or more risk factors for
ulceration
Neuropathy and Ischaemia are the
main risk factors
Deformity, oedema and callus may not
lead to ulceration unless one or both of the
main risk factors are present

43. Edmonds Classification
• Stage 3 – Skin breakdown occurs usually
as an ulcer, but injuries such as grazes,
bruises and blisters can eventually
become ulcers
• Stage 4 – Infection can complicate both
the neuropathic and ischaemic foot
• Stage 5 – Necrosis can further lead to
tissue destruction
• Stage 6 – The foot cannot be saved

44. Edmonds Classification
Exceptions to this classification include
• Charcot’s foot
• Neuropathic fractures
• Painful neuropathy

45. Management
• Regular inspection and examination
• Multidisciplinary team
• Patient education
• Assess risk of foot
• Non ulcer pathology
• Ulcers and related pathology

46. Patient Education
• Optimum Glycemic control
• Management of co-morbid conditions
• Stop Smoking
• Warning signs

47. Foot Care
• Daily Routine and Inspection
• Between toes and below foot
• Nail Care: trim wet, straight across, proper
clippers (NO KNIVES)
• Skin Care: Moisture, Callus
• Footwear: Proper fit, clean
• Avoid excessive heat (Radiators, Hot
water, hot pitch)
• Avoid OTC Corn/Callus medications
• NEVER WALK BAREFOOT

49. Non Ulcer Pathology
• Calluses & Nails – Podiatrist
• Skin pathology
• Foot deformities – Surgical / Orthopedic
consult

50. Ulcer Pathology
• Treat the Cause(s) and co-morbid factors
• Psychosocial Factors
• Relief of mechanical pressure and protect
ulcer from stress
• Local Wound Care
• Treatment of Infection: Abx (Broad
Spectrum, multiple), Drainage,
Debridement
• Moisture control: Dressings
• Outpatient or Inpatient Care

52. Ulcer Pathology

53. Ulcer Pathology
• Low Threshold for Referral
• Stage 3 and above associated with poor
control

55. Conclusion
• Diabetic foot is a serious complication
• Associated with poor control
• Prevention requires vigilance and patient
education
• Treated by a multidisciplinary team

56. Thank You
• Questions?

57. References
1. Edmonds ME, Foster AVM, Sanders LJ.
A Practical Manual of Diabetic Foot Care
2nd Ed. Blackwell Publishing 2008
2. Radwan M. The Diabetic Foot: An
Overview [Internet] cited 1st June 2012
Available from:
www.mansdf.edu.eg/Videos_presentation
s/DF-overview.pdf
3. National Institute of Health. Feet can last
a Lifetime NIH and CDC. 2010