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Education Material for Health Care Professionals: Book Version

THE FEET AND DIABETES

Clinical features of neuropathic and ischaemic foot

Neuropathic Ischaemic (neuroischaemic)
Warm with intact pulses Pulseless, not warm
Diminished sensation Usually diminished sensation
Ulceration, usually on tips of toes and plantar surfaces under metatarsal heads Ulceration, often on margins of foot, tips of toes, heels
Sepsis Sepsis
Local necrosis Necrosis or gangrene
Oedema Critical ischaemia, foot pink, painful, pulseless, and often cold
Charcot's joints  

Whilst nerve involvement and the peripheral vascular disease predispose to foot problems, there is usually seen a “trigger” or precipitating factor. This can be trauma, or infection or both. Therefore, the focus in preventing serious foot complications would aim at efforts to avoid trauma and infection to the feet or in the least, diagnose their presence in the very early stages so that adequate measures can be taken at a time when management of the patient would be simpler.

Precipitating causes of foot ulceration and infection
Friction in ill fitting or new shoes
Untreated callus
Self treated callus
Foot injuries (for example, unnoticed trauma in shoes or when walking barefoot) Burns (for example, excessively hot bath, hot water bottle, hot radiators, hot sand on holiday)
Corn plaster
Nail infections (paronychia)
Heel friction in patients confined to bed
Foot deformities (callus, clawed toes, bunions, pes cavus, hallux rigidus, hammer toe, Charcot's foot, deformities from previous trauma or surgery, nail deformities, oedema)


Danger signs

  1. Redness and swelling of a foot that even when neuropathic causes some discomfort and pain; this often indicates a developing abscess, and urgent surgery may be needed to save the leg;

  2. Cellulitis, discolouration, and crepitus (gas in soft tissues);

  3. Pink, painful, pulseless foot even without gangrene indicates critical ischaemia that needs urgent arterial investigation followed by surgical intervention whenever possible.

Whilst all patients should have intensive foot care education, there are certain categories of patients who are more at risk of having foot problems and would need a much more specialised care and attention.

Patients with HIGH RISK
a) patients who walk barefoot.
b) patients with diabetic neuropathy.
c) patients with significant peripheral vascular disease.
d) patients who smoke or use tobacco in any form.
e) those with a foot deformity such as claw toes and hallux valgus.
f) diabetics with a history of previous ulcers or foot infections.
g) patients with abnormal gait.
h) those with significant skin and nail infections or deformitoes.
i) blind/partially sighted persons.
j) elderly patients ; especially those living alone,
k) diabetics with chronic renal failure;
l) patients with a high alcohol intake.
Importantly,

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