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 training module on how to undertake a foot assessment and use the online Foot Screening Tool www.diabetesframe.org
  • 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 - and provided with written information.  Leaflets are accessible from within the SCI-Diabetes Foot Screening tool or by clicking here.
  • All people with diabetes should receive information and education in foot care, relative to their risk score to reduce the incidence of ulceration, gangrene and amputation. www.mydiabetesmyway.scot.nhs.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 annual foot examination from a suitably trained Health Care Professional.
  • To provide a structure whereby patients are directed to the most appropriate level of foot care in accordance with their foot risk score.

 

Foot Assessment

 

There is an online FRAME training module which explains the purpose of foot screening, demonstrates how to carry out a foot assessment and how to use the online SCI-Diabetes foot risk tool to calculate and record foot risk score.  There is an assessment involving case scenarios at the end of the modules which the learner may opt to undertake and which, if passed, gives a certificate of completion.  Click here to launch the tool.  It takes approximately 20-30 minutes to complete.

 

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

LOW RISK

Patients with a LOW risk score 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 should be referred directly to Podiatry. The referral will be triaged by a podiatrist and an assessment appointment will be issued to the most appropriate member of the podiatry team.

 

ACTIVE FOOT DISEASE

Patients with ACTIVE FOOT DISEASE should be referred directly to Podiatry. An urgent appointment will be issued to attend a Diabetes Specialist Podiatrist. These clinics are available at Perth Royal Infirmary, Ninewells Hospital, Arbroath Infirmary, Forfar Whitehills Community Hospital and Montrose Links Health Centre.

Referrals which require input from a Diabetes Specialist Podiatrist include:

  • Non-healing ulcers of longer than 4 weeks duration
  • Suspected Osteomyelitis, this may be diagnosed by X-ray, but radiological changes can take several weeks to develop.

Completed SCI-Diabetes/Footstep Referral Forms with risk score should be sent to:

Podiatry Office, Westgate Health Centre, Dundee, DD2 4AD

Podiatry Office, Perth Royal Infirmary, PH1 1NX

Podiatry Office, Whitehills Hospital, Forfar, DD8 3DY

If risk score not indicated the referral will be sent back to the referrer.

Diabetic Foot Emergencies

Please contact the Diabetes Specialist Podiatrist directly when any of the following is present:

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

 

Dundee: Brian McMurray or Joanna Donaldson, Strathmore Diabetes Centre, Ninewells Hospital, Tel 01382 660111 ext 33509

Perth: Vicky Green, Perth Royal Infirmary, Tel 01738 473759 or ext 13759

Angus: Kay Brown or Susan Reid, Whitehills Community Hospital, Forfar, Tel 01307 475056

 

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 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 referred directly to the vascular team

Patients with Severe Infection (systemic toxicity) should be considered for urgent medical admission.

 

 

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.

  • 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. This can be achieved by the use of orthoses via referral to orthotic department, total contact casting or Scotch cast boots.

 

 Orthotic Guidelines and Treatment Table

  • Footwear advice
  • Custom moulded insoles
  • Footwear and custom moulded insoles
  • Orthoses for ulcer management
  • Charcot

 

Footwear advice

Patient showing evidence of mild foot deformity with no neuropathy or ischaemia, and whose feet could easily be accommodated in shop bought footwear, should be provided with appropriate footwear advice.

 Leaflets providing information as to appropriate footwear for diabetic feet can be issued by orthotic department.

Custom moulded insoles

Custom moulded insoles have been proven to reduce areas of high presure by re-distributing it more evenly across the whole plantar surface of the foot.

Patients showing evidence of high pressure, such as callus, on the plantar aspect of the foot, including toes, should be referred to orthotic department for insole assessment.

Patients with prominent metatarsal heads, or reduced fatty padding in this area, should be referred to orthotics for insole assessment.

Patients with evidence of trauma (blistering or bruising) on the plantar aspect of the foot, or those who have a previous ulcer history, should be referred to orthotics for insole assessment.

 

Footwear and custom moulded insoles

Footwear and custom moulded insoles have been proven to reduce callus thickness and ulcer recurrence.

Patient showing evidence of foot deformity resulting in high pressure on non-plantar surface of the foot, in particular the dorsum of all toes and the medial and lateral metatarsal joints, and have neuropathy and/or ischaemia should be referred to orthotics for footwear and insole assessment.

Orthoses for ulcer management

There is evidence to support the use of orthoses to increase the healing rate of diabetic foot ulcers.

Patients presenting with ulcers on the plantar or dorsal surface of the foot, the heel or the ankles should be referred to orthotics for formal assessment.

Orthotics will also be accessed via the Diabetes Foot Clinic.


Charcot

Neuropathic arthropathy, most commonly found in ankle and mid-tarsal joints.

Patients with suspected charcot, warm, painful, inflamed joints with or without deformity, require to be formally assessed for charcot. If it is found to be present, complete rest is required and an immediate referral to a diabetic foot clinic is essential.

The state of the charcot joints, active or non-active, determines the treatment provided.

Active state – Aircast walkerä to immobilise the foot and ankle, preventing further deformity.

Non-active state – Custom made insoles and footwear to maintain foot position and re-distribute plantar pressures.

   

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Management Guidelines for Charcot Neuroarthropathy

Charcot Foot is a neuroarthropathic 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 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 contralateral foot
  • 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 Aircast Boot. 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) however there are a number of studies that indicate that Bisphosphonates may be useful in halting the acute phase of Charcot neuroarthropathy in some patients. (Anderson et al 2004, Jude et al 2001). All suspected Charcot Foot cases to be reviewed by Consultant Physician to consider options.
  • Discontinue therapy when foot temperature equal.

 

Long Term Management

  • Long- term pressure relief with (orthotic) orthopaedic footwear and orthoses. Refer to Orthotist.
  • Classify patient as high current risk and review regularly for signs of long- term complications. (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 localized.  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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