High blood sugars cause ____
- nerve damage
- arterial damage
- large and small vessels
- large = coronary arteries and large LE arteries
- small = arterioles, capillaries, venules; damage to eyes and kidneys, most vulnerable
- even though ABI may be considered normal, the foot may be functionally ischemic - lead to endothelial dysfunction - Vessels can’t dilate in response to injury resulting in decreased blood flow and oxygen/nutrient transport
What are the causes of foot ulceration?
- Sensory neuropathy- 50% of patients unaware they have lost protective sensation (unable to feel 5.07 monofilament)
- Autonomic neuropathy - Dry, cracked, fissured skin due to decreased ability to sweat
Increased rate of callus formation - Motor neuropathy - Intrinsic muscle weakness/atrophy; Decreased foot stability; Leads to deformities; Increased pressure/shear forces to the foot
- Mechanical stress on the foot - Abnormal or excessive forces predispose to ulceration
Current recommendation is checking diabetic patients at least ___
5.07 monofilament = grams of pressure
Tuning fork may also be used at
4x/year
10
128hz
What is the classification on the Wagner classification system?
0 - no open lesion; may have deformity or cellulitis
1 - superficial ulcer
2 - deep ulcer tendon, capsule, boe
3 - deep ulcer with abscess, osteomyelitis, or joint sepsis
4 - localized gangrene
5 - gangrene of the entire foot
What are the characteristics of a diabetic ulcer?
- Predominantly on the plantar foot - Usually over a bony prominence; May be anywhere below the knee
- Dry, minimal exudate unless infected - usually has callused periwound
- Pale wound bed - Necrotic tissue uncommon unless infected
- Round punched out appearance
- Painless
- Pulses and temperature are normal
What are the most common locations of diabetic ulcer? best dressing for it?
heel , ball of foot, big toe
abnormal callus formation; Callus is a thick layer of dead tissue that builds up due to increased pressure/friction; Always remove
Hyperkeratosis
- make sure pts know not to remove themselves
What foot deformities are sene with peroneal nerve damage?
- equinovarus
2. increased forefoot pressure
What foot deformities are sene with tibial nerve damage?
- calcaneovalgus
- increased heel pressure
- if subtalar joint subluxes leads to Charcot foot
a condition causing weakening of the bones in the foot that can occur in people who have significant nerve damage (neuropathy); The bones are weakened enough to fracture, and with continued walking the foot eventually changes shape; As the disorder progresses, the joints collapse and the foot takes on an abnormal shape, such as a rocker-bottom appearance
Charcot foot
What are the key points to teach pt’s for proper foot care?
- Daily foot inspection is a must!
- Always wear shoes to prevent trauma - No sandals; Cotton or wool socks
- Properly fitted shoes - Custom shoes are necessary if deformities are present; Medicare allows one pair of custom shoes and 3 inserts per year
- Regular podiatry visits to remove calluses and trim nails
- Keep skin moisturized - Avoid lotion between toes; Dry between toes after shower
- Never soak feet - Will cause maceration and lead to increased risk of infection
What factors optimize healing?
- Maintenance of normal blood sugars - A1c of 6 or less (mean glucose of 126 over past 3 months)
- Eliminate sources of trauma with proper footwear
- Offload pressure - 92% heal with offloading alone; Don’t feel pain so don’t want to stay off of it
- Reduce bioburden with antimicrobial dressings
- Moist wound healing
What is the role of a dietitian in diabetic wound healing?
- Dietician is crucial with all non-healing diabetic wounds
- Get lab results - Prealbumin, total protein, Hgb
- Is a supplement needed? - Vitamin C, Zinc, Vitamin A, Iron, Amino Acids
- Look at hydration
- Calorie intake
Consequence of high blood sugars and small vessel disease; Poor glucose control leads to impairment of WBC function and ability to fight infection; Most common reason for hospital admission for diabetic patients; Precursor for most amputations; Streptococcus + is most common organism
infection
Gold standard for off loading a diabetic ulcer; Modified short leg cast used for Wagner grade 1 or 2 ulcers; Assists wound healing
Total contact casting
- Immobilizes foot and ankle dispersing weight-bearing forces over large area
- Cast rigidity controls edema
- Immobilization of foot protects from trauma
- Assists with patient compliance
What are contraindications for total contact casting?
- Untreated osteomyelitis
- Dermatitis
- Fluctuating/unpredictable edema
- Active infection
- ABI less than 0.5
- Claustrophobia
What are some alternative offloading methods to a total contact cast?
- Orthowedge healing shoe
- Darco shoe inserts
- Molded shoes/shoe inserts
- Provides safe ambulation, pressure reduction, room for bandages
What are some adjunct therapy used for wound healing
- Growth factors – Regranex
- E-stim - Underwater/immersion
- Hyperbaric oxygen
- Pulsed lavage/wound cleansing - 4-15 PSI’s is range needed to wash bacteria out and not harm healthy tissue
what are some things to consider when doing gait and mobility training with a pt with diabetic ulcers
- PWB gait with assistive device - beeper boot
2. Alter gait pattern to decrease plantar pressure - Step-to pattern; Slower steps
What are therapeutic exercises used in pts with diabetic ulcers?
- ROM Exercises - Assess/address great toe extension, talocrural dorsiflexion, and subtalar joint motion; Joint mobilizations may be helpful
- Aerobic Exercise - Assists with glycemic control; Assists with weight loss (5-10% body weight makes a huge difference)
What things should be considered when getting permanent/ custom footwear?
- Conforms to foot, soft and moldable
- Should be ~½ inch longer than the longest toe with snug heel fit
- Toe box deep/wide enough for toe spread and clearance
- 1st MTP joint widest part of shoe
- Heel height < 1 inch
- Adjustable lace/straps
- Soft inserts may decrease pressure
- Fit shoes in the middle of the day
- Break in shoes gradually
- Patients with severe foot deformities or amputations should be referred to an orthotist`
Diabetes statistics:
23 million are currently diagnosed
- Up to __% will get a foot ulcer in their lifetime
__ million are undiagnosed
__% of all amputations start with a foot ulcer
25%
7
85%
