Dr Sue Benbow: Diabetes is one of the biggest
health challenges facing the UK today. Merseyside is no exception, with over 70,000 people already
diagnosed with the condition and the numbers are increasing year on year. Disease of the
foot is a complication of diabetes caused by either damage to the nerves or the blood
vessels that service the limbs. But, worryingly, one in three people with diabetes don’t realise
that having the condition puts them at increased risk of having an amputation. The literature
suggests that 15 per cent of the population with diabetes will experience an ulcer during
their lifetime, with 6 per cent having an amputation – a complication that is both costly
to the individual and to the NHS. But if the incidence of ulcers and amputations could
be reduced by intensive preventative measures, there could be a significant saving to both
the NHS and to the individual. Diabetes is the commonest cause of non-traumatic amputation
in the UK, with up to 80 per cent of amputations being preceded by a foot ulcer. However, ulceration
and amputation should not be seen as an inevitable consequence of diabetes. Many foot ulcers
and amputations could be prevented. The early identification of the at-risk foot, combined
with patient education and the application of other preventative measures, as well as
the rapid treatment of complications by the multidisciplinary foot-care team, should help
avoid this scenario. So what are the principles of good foot care? These should be – simple,
visual examination of both feet at least once every year as an essential management of the
person with diabetes, no matter where they’re seen. All clinical staff seeing people with
diabetes should be trained and competent in undertaking a basic foot check. The potential
threat of active foot disease should also be recognised by non-specialist health-care
professionals. Screening the foot is vital, but once assessed, the person should have
the risk level classified as low, increased or high current risk and, where necessary,
action must be taken to reduce future problems. Where active foot disease is found, it requires
a relevant history to be taken, a thorough examination and immediate referral onwards
to a multidisciplinary foot-care team with the necessary skills in the management of
the diabetic foot. Helen Pendlebury: There are two main conditions
that affect the foot due to diabetes. These are peripheral neuropathy, which affects feeling
and peripheral arterial disease, which results in reduced circulation. Diabetic peripheral
neuropathy is defined as the presence of symptoms and/or signs of peripheral nerve dysfunction
in people with diabetes after the exclusion of other causes. One of the symptoms of neuropathy
can be the loss of protective sensation in the feet. A person with loss of protective
sensation could injure their foot and be completely unaware of any resulting problems. Peripheral
arterial disease causes calcification, arterial narrowing and blockage of blood vessels, which
can result in reduced blood flow to the feet. This can manifest itself in many ways and,
in particular, it may cause pain when walking or at rest and result in a reduced ability
to heal. To start a diabetic foot screening, sit the patient on the examination couch with
their shoes or socks or stockings removed. Inform them that you are going to examine
their feet and carry out a diabetic foot screening to check their risk of developing any diabetic
foot complications. All the results of the baseline foot examination should be recorded
on the baseline foot-screening form or on the GP template. Firstly, check if the patient
has suffered any previous amputation. The next stage of the screening process is to
check the general shape of the feet for any nail or foot deformities such as pes cavus,
claw toes or hallux valgus, all of which could increase the patient’s risk of developing
foot complications. Check both feet for any areas of significant callus or dry skin, paying
particular attention to the heel area. Check between the toes for problems such as athlete’s
foot, soft corns or fissures. Check both feet for areas of ulceration and ask the patient
if they have suffered any previous ulceration. Check if the patient is able to self-care.
This can be done by checking if the patient can reach their feet with ease and if they
are able to see their feet clearly. Check if there are any other risk factors present,
such as nail pathologies or inappropriate footwear. The next stage of the screening
process is to check the patient’s circulation to their feet. There are two pulses we look
for in each foot – the dorsalis pedis and the posterior tibial. To find the dorsalis
pedis pulse, palpate the foot between the first and second metatarsals. Note that the
dorsalis pedis pulse is absent in about ten per cent of the population. To find the posterior
tibial, palpate the area behind the medial malleolus. Record whether each pulse is present
or absent. Ask the patient if they are experiencing intermittent claudication – which is pain
or tightness in the calves on walking, relieved by stopping – or if they have had any previous
vascular intervention. The next test we carry out is for diabetic neuropathy. This is to
easily enable us to check if the patient’s protective sensation is intact. For this test,
we use a 10-gram monofilament. It is important that you only use reputable makes of monofilament,
such as manufactured by Bailey Instruments and Owen Mumford. This will ensure the information
you are collecting is accurate. The monofilament must be rested for 24 hours after ten patients
and replaced after 100 uses. The advantages of this test are its simplicity, accuracy
and low cost. Studies have shown that inability to feel a 10-gram monofilament is a useful
test as a predictor of future occurrence of diabetic foot ulcers. Inform the patient you
are going to test the sensation in their feet with the monofilament. Show the patient that
it is not sharp by first testing it on their hand. You may need to test it on the patient’s
elbow or forehead if the patient has neuropathy affecting their hands. Patients must have
their eyes closed so they cannot see where the filament is being applied. The monofilament
should be applied perpendicular to the surface of the skin and with sufficient pressure to
cause a slight bend in the filament. If it is kinked, it will need to be replaced. Test
on the plantar aspect of the first toes and the first and fifth metatarsal heads, as demonstrated.
Avoid testing areas on the foot where there is callus present, areas of ulceration or
scar tissue. You may have to test proximally or distally when any of these are present.
Do not make any repetitive contact or allow the monofilament to slide across the skin.
Press the filament to the skin and ask the patient if their feel pressure and next where
they feel the pressure being applied. Clinician: Can you feel that? Patient: Yep, like, underneath me big toe. Clinician: Can you feel that? Patient: Yep. Underneath me little toe. Clinician: Thank you. Can you feel that? Patient: Yep. Underneath me other big toe. Helen Pendlebury: Repeat this application
twice at the same site, but alternate this with at least one mock application in which
no filament is applied. Clinician: Can you feel that? Patient: No. Clinician: Can you feel that? Patient: No. Helen Pendlebury: This gives a total of three
questions per site. The total time from contact to removal of the monofilament should be approximately
two seconds in duration. Protective sensation is present at each site if the patient correctly
answers two out of three applications. Protective sensation is absent with two out of three
incorrect answers and the patient is considered to be at risk of ulceration. Ask the patient
if they are experiencing any pain or paresthesia, often described as tingling or burning in
their feet and record as appropriate. The findings from these tests will enable the
patient’s risk category to be recorded on the form. Following the pathway with then
determine if the patient needs to be referred to another health-care professional, such
as a podiatrist, or whether they can receive the appropriate foot-health education and
continue to be screened annually at the practice. We are now going to carry out a simple diabetic
foot screening on our patient in a clinical situation. Firstly we check that there have
been no previous amputations. We then check the general shape of the foot for any structural
abnormalities. Check for any callus, paying particular attention around the heel areas.
Check between the toes for any problems such as athlete’s foot or fissuring. Ask the patient
if there has been any previous ulceration. Check if the patient is able to self-care
by being able to reach and see their feet easily. We then check the two pulses on either
foot. Firstly the dorsalis pedis and then the posterior tibial. We are now ready to
carry out the neurological test, using the monofilament. We test the plantar aspect of
the first toes and the first and fifth metatarsal heads, recording as appropriate. Clinician: Just going to check the sensation
in your feet. If I just show you this – it’s a very light touch. I’ll just show you on
the underside of your arm. Smashing. I’m going to touch different parts of your foot. If
you can just say “yes” when you feel it touching, just describe where you think it’s touched,
OK? Close your eyes for me as we do the test. Can you feel that? Patient: Yep, on my big toe. Clinician: Can you feel that? Patient: Yep, like, underneath me big toe. Clinician: Can you feel that? Patient: Yep. Underneath me little toe. Clinician: Thank you. Can you feel that? Patient: Yep. Underneath me other big toe. Clinician: Can you feel that? Patient: Yep, underneath me big toe. Clinician: Can you feel that? Patient: No. Clinician: Can you feel that? Patient: Yep, underneath me little toe. Clinician: Can you feel that? Patient: Yep, like, underneath me big toe. Clinician: Can you feel that? Patient: No. Clinician: Can you feel that? Patient: Yep. Clinician: Whereabouts did that last one feel
like? Patient: Erm, underneath my little toe. Clinician: That’s great. OK, you can open
your eyes now. Patient: Thanks. Helen Pendlebury: Once you have completed
the patient screening, you will enter all the relevant findings on the baseline foot-screening
form. Following a diabetes foot screening, patients should be categorised into low risk,
increased risk, high risk or foot ulcer. If a patient has palpable pulses and normal sensation,
the left-hand side of the pathway will be followed and the patient classified as low
risk. The patient should be encouraged to continue with their own foot care. Low-risk
verbal advice should be given and supported by a low-risk advice leaflet. A diabetes foot
screening should be completed annually. Where a patient has neuropathy or absent foot pulses
or has a risk factor which impacts on foot health, such as inability to self-care, foot
or nail deformity and pathological callus, the patient should be categorised as increased
risk. This is the blue section on the foot-screening pathway. All these factors require podiatry
management. The patient should be referred directly to the local podiatry department.
Following podiatry assessment and management plan, any advice will be supported with an
increased-risk advice leaflet. Ideally, the management plans should be reviewed every
three to six months and annual diabetes foot screening will follow within the podiatry
service. Where a patient has neuropathy or absent foot pulses and foot deformity or pathological
callus, the patient should be categorised as high risk. This is the yellow section of
the pathway. A high-risk advice leaflet for neuropathy or poor circulation or deformity
is supplied by a podiatrist in support of any verbal advice given following a podiatry
appointment. Ideally, the patient should be reviewed by a podiatrist every one to three
months and annual foot screening will ensue. If a patient presents at a foot-screening
consultation with a chronic or stable diabetes foot ulceration, this represent the foot ulcer
or red section of the pathway. A foot-ulcer leaflet will be given followed by referral
to the diabetes multidisciplinary foot-care team and to the podiatry service. Where a
patient may present with critical ischaemia, spreading cellulitis, severe infection or
acute charcot osteoarthropathy, this is classed as a foot emergency. Immediate referral should
be made to A&E or admission arranged via the patient’s GP. The next available appointment
should also be made at the multidisciplinary foot-care team for further investigations
and assessment. This is as directed in red at the bottom of the pathway. Fred: In my opinion, it’s important for me
to get my feet checked on a regular basis because of the nerve damage that diabetes
induces on your feet and it’s important that, on a day-to-day basis, I get a check done,
but I also get a check done by a professional. They can tell if there’s anything that’s actually
going wrong with it that I can’t detect. Joan: I see annual foot screening as an essential
in my diabetes care. It means a lot to me and I do go regularly to get it done because,
long term, as I say, it can cause problems and, after this length of time, I prefer to
keep problems away rather than encourage them. When I go for my foot-screening appointment,
the podiatrist normally checks the nerve sensation, checks the circulation and it’s not painful,
it’s no problem and the maximum, I would say, about ten minutes. Fred: My immediate results with my foot screening
are there and then and the other information I need about that is given to me in that I
might have to go and see somebody else for further screening. Joan: When the foot screening has been done,
they normally give you the results at the end of it, they usually say what risk you
are, whether it’s low, moderate or high risk. And then you’re given information on… you’re
given a leaflet about the risk factor involved and you’re also given advice on who to contact
should there be a problem before your next foot-screening appointment. Fred: If you are a bit nervous about getting
your feet screened, you actually don’t need to be nervous about it because it’s quite
a quick and easy process and it’s important, if you have got diabetes, that you’re able
to get it checked and your doctor will either check it himself or herself or will pass you
on to somebody, a podiatrist, who has a better understanding of how the feet are and should
work. Joan: It’s something that you really need
to do because, long term, diabetes can have horrendous complications and the sooner you
do something, the better. You know, it is very important, certainly from my viewpoint,
and with doing what I’ve been doing, I’ve now gone 50 years without… with very few
complications and I think that’s been as a result of making sure that I get screening
for feet and any other areas that need checking. Dr Sue Benbow: We hope that the production
of this DVD will help both health-care professionals and patients understand the importance of
foot screening and that regular and correct foot screening and risk stratification is
an essential part of diabetes care.

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