Tayside Diabetes MCN Handbook 
Screening and Management of Foot Complications

Screening and Management of Foot Complications

HCPC registered podiatrists play an important role in the education, assessment and treatment of patients in the management and prevention of lower limb diabetic complications.

• All patients with diabetes should be screened to assess the risk of developing a foot ulcer.
• Health professionals should use the online FOOT SCREENING TOOL within SCI-DIABETES to record the outcome of the screening.
• There is an online learning module on how to undertake a foot screening and to use the online Foot Screening Tool (http://www.diabetesframe.org) Please note this needs to be accessed using Google Chrome as this site doesn't work with Internet Explorer.
• The level of intervention required depends upon the risk stratification which is automatically calculated using this tool.
• All people should be informed of their risk of foot ulceration - low, moderate or high/ in remission. 
• All people with diabetes should receive education in foot care, relative to their risk score to reduce the incidence of ulceration, gangrene and amputation.  Leaflets can be located under publications on: (www.diabetesinscotland.org.uk)

Aims of Diabetic Footcare Advice

• Education of patients and/or carers on the importance of self-care
• Prevention of trauma and subsequent development of foot lesions
• To aid healing of established lesions and prevention of recurrence
• To maintain patient mobility and avoid hospital admission

Objectives of Diabetic Footcare

• To provide all patients with diabetes with education to support them in the management of their own foot health.
• To ensure that all patients receive a foot examination from a suitably trained Health Care Professional, every one or two years depending on risk score.
• To provide a structure whereby patients are directed to the most appropriate level of foot care in accordance with their foot risk score.

Foot Screening

The SCI-Diabetes Foot Screening Tool can be found by clicking on the “Foot Screening form” icon within the patient’s SCI-Diabetes Patient Summary Data Screen.  A screen shot of the tool is below.

Testing Pressure Sensation with a Monofilament (with hosiery removed)

• Monofilaments are designed to deliver a standard stimulus independent of the pressure applied
• Test a total of 10 sites: 1st, 3rd & 5th plantar metatarsal heads, plantar aspect of great toe and apex of 3rd toe in both feet.
• If the patient is UNABLE to feel the monofilament at 3 or more sites, then neuropathy would be identified as being present.

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 Risk Stratification for Diabetic Foot Disease

Referring to Podiatry

Referrals to podiatry can either be submitted via SCI-Gateway; or by completing a Podiatry Health Care Professional Referral Form and emailing it to: tay.taysidepodiatry@nhs.scot with subject marked Dundee, Perth or Angus. If the foot risk score is not indicated, the referral will be sent back to the referrer.

Referrals submitted using the generic SCI-Diabetes referral form for Podiatry, including Footstep will still be accepted but further information may be asked for to support appropriate triage.

LOW RISK

Patients with a LOW risk score that require education on personal footcare, should be referred directly into Footstep via Podiatry. An invitation to attend an educational session in self-management will then be sent to the patient by podiatry. A clinical appointment with a podiatrist will only be issued if a clinical problem has been identified.

MODERATE AND HIGH RISK

Patients with a MODERATE or HIGH risk score that have transitioned from low or moderate or who have never been seen by a podiatrist should be referred directly to Podiatry. The referral will be triaged by a podiatrist and an assessment appointment will be issued to a member of the podiatry team who will then decide what ongoing care is appropriate for that individual.  Patients who already attend an HCPC Registered Podiatrist outwith the NHS, should be given the option to make an appointment independently with their usual podiatrist in order to have their foot assessment carried out and the outcome entered by the podiatrist via My Diabetes My Way. 

ACTIVE FOOT DISEASE

Patients with ACTIVE FOOT DISEASE should be referred directly to Podiatry. In line with the national foot risk stratification definition, Active Foot Disease is the presence of active ulceration, infection, gangrene; or an unexplained hot, red, swollen foot with or without presence of pain.

Diabetic Foot Emergencies

Please contact the podiatry department immediately when any of the following is present:

• SPREADING INFECTION (Antibiotic guidelines)
• AN ULCER THAT IS DETERIORATING
• SUSPECTED CHARCOT  

A Multidisciplinary Diabetes Foot Clinic is held weekly in the Diabetes Centre at Ninewells Hospital. This has input from a Diabetologist, Podiatrists, Orthotist, Diabetes Specialist Nurse and has access to the Vascular Surgery team. Referrals to this clinic can only be made by a member of the multidisciplinary foot team.

Critical Limb Ischaemia, including rest pain should be referred directly to the vascular team

Patients with Severe Infection (systemic toxicity) should be considered for urgent medical admission to the Acute Medical Unit (AMU).

Management of Diabetic Foot Ulceration 

The Tayside Diabetes Foot Service does not advocate the use of antibiotics for all patients with foot ulcers. They should be reserved for ulcers which show clinical signs of infection. (e.g. IDSA Guidelines)

• Refer to the Tayside Wound Formulary, Section13 on Wound Infection
• Refer to the Tayside Wound Formulary Section 7 on Diabetic Foot Ulcers for advice on dressings
• Antibiotics - see attached for summary of guidance on antibiotics for infection in the diabetic foot.
• Cardiovascular risk factors should be treated aggressively for all such patients.

Debridement of Ulcers

Clinical experience suggests that in an appropriate setting local sharp debridement, surgical debridement, larvae therapy, can be useful in the management of patients with diabetic foot disease. Local sharp debridement should be considered first followed by the others depending on the clinical presentation or response of a wound and by a suitably trained professional.

Pressure Relief

•  There is evidence to support the use of orthoses to reduce plantar callus thickness and ulcer recurrence.
•  Patients with ‘at risk’ feet should be referred to orthotics for assessment for diabetic specification footwear and insoles.
• Ulcers will only heal if there is effective pressure relief.

 Redefining and Demystifying Offloading for Diabetes Foot Care

 PDF version available here

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Management Guidelines for Charcot Neuro-arthropathy

Charcot Foot is a neuro-arthropathic process with osteoporosis, fracture, acute inflammation and disorganisation of foot architecture. (SIGN 116). This affects <1% of the diabetic population.

Clinical features

• Diabetes patient presents with red, oedematous, hot and possibly painful foot.
• Usually bounding pedal pulses with evidence of possible impaired neurological testing.

Diagnosis / Investigations

“Diagnosis should be made by clinical examination”. (Frykberg et al 2000; Jeffcoate et al 2000)

• Usually a good blood supply to lower limb with degree of neuropathy.
• Observe foot for obvious signs of tissue trauma, cellulitis or systemic toxicity to rule out infection.
• History of trauma to limb may be present.
• Heat differentiation between limbs – affected limb often 2-8 degrees higher than the other limb
• Blood test HbA1c, Hb, ESR and C-reactive protein.
• X-Ray for baseline and to exclude diabetic neuropathic fracture
• If Charcot foot suspected consider MRI / Bone Scan

Management

“Refer people with suspected Charcot`s Foot immediately to a member of the multidisciplinary foot care team for immobilisation of the affected joint(s) and for long- term management to prevent ulceration”. (NICE 2011)

• Off loading urgently required ideally with either Total Contact Casting or removable cast walker. Pressure relieving footwear usually worn until inflammation settles, heat differentiation disappears and bone activity reduces. (SIGN 116)
• Patient education. Patients require education on the causes and management of Charcot foot and advice on prevention of complications(http://www.mydiabetesmyway.scot.nhs.uk/)
• There is insufficient evidence to support the routine use of Bisphosphonates in the acute Charcot Foot (SIGN 116). All suspected Charcot Foot cases to be reviewed by Consultant Physician to consider options.
• Discontinue therapy when foot temperature difference between the feet is 1-2 degrees or less.

Long Term Management

• Long- term pressure relief with (orthotic) orthopaedic footwear and orthoses. Refer to an Orthotist.
• Classify patient as high current risk and review regularly for signs of long- term complications e.g. history of ulceration, amputation. (NICE 2011)

References
Anderson et al (2004). Bisphosphonates for the treatment of Charcot neuroarthropathy. Jn. foot and Ankle Surg, 43 (5); p 285-9. Fryberg RG and Mendeszoon E (2000). Management of the diabetic Charcot foot. Diabetes Metab Res Rev; 16 S59-65.

Jeffcoate et al (2000). The Charcot foot. Diabetic Medicine, 17 (4): p253-8. Jude et al (2001). Bisphosphonates in the treatment of Charcot neuroarthropathy: a double-blind randomised controlled trial. Diabetiologia; 44 (11) p2032-7. Nice (2011) Type 2 Diabetes: prevention and management of foot problems. SIGN (116).  ection 11: Management of diabetes foot disease.  

Painful Peripheral Neuropathy

 Distal symmetrical neuropathy may be symptomless initially but put the feet at risk due to loss of pain sensation. Later, numbness, paraesthesiae, burning pain and contact sensitivity (allodynia) may develop and these symptoms are often difficult to treat. 

 General

• Improve glycaemic control
• Exclude or treat other factors e.g. alcohol excess, vitamin B12 deficiency

 Pharmacological

• Simple analgesics e.g. aspirin, paracetamol, codeine phosphate should be tried initially
• Tricyclic anti-depressants (TCAs) e.g. Amitriptyline given at bedtime should be considered as first line therapy unless contra-indicated (SIGN 116)
• Gabapentin is also recommended and is associated with fewer side effects than TCAs and older anti-convulsants
• Duloxetine (60mg) or Pregabalin (50mg bd – 200mg) can be tried as the next alternative. Gabapentin can be used but careful dose titration is required
• Topical Capsaicin cream may be applied sparingly to the affected area if the pain is very localised.  It may take several weeks to work and patients should be warned of this
• Allodynia may respond to use of a plastic film e.g.”Op-site” applied to the affected area
• Stronger opioids such as Oxycodone or Tramadol can be used

 Other

• For persistent severe symptoms, consider referral to the Pain Clinic

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