ADA Endorses Protocol for Diabetic Foot Care

Abstract

Mark S. Lesney is a senior editor with Elsevier Global Medical News. A simple protocol can assess the diabetic foot for predisposing factors for ulcerations and amputation and can guide treatment, according to an American Diabetes Association task force. The protocol consists of a history, general examination, and an assessment of dermatologic, musculoskeletal, neurologic, and vascular factors. Details of the protocol were issued in a report by Andrew J. M. Boulton, MD, and his colleagues in a task force of the ADA's Foot Care Interest Group. The history should explore foot ulceration or amputation, neuropathic or peripheral vascular symptoms, impaired vision, renal therapy, and tobacco use. Key components of the diabetic foot exam include dermatologic inspection for skin status, sweating, infection, ulceration, and calluses, as well as musculoskeletal inspection for deformity (such as claw toes) or muscle wasting. Neurologic assessment for loss of protective sensation (LOPS) should include a 10-g monofilament test on the bottom of the foot while the patient's eyes are closed, as well as one of these tests: ▸ Vibration using a 128-Hz tuning fork. ▸ Pinprick sensation. ▸ Ankle reflexes. ▸ Vibration perception threshold testing. Vascular assessment using ankle brachial pressure index testing should be performed to determine the presence of peripheral arterial disease (PAD) in two groups of patients: those who are symptomatic (claudication, rest pain, or nonhealing ulcer) and those who have absent posterior tibial or dorsalis pedis pulses (Diabetes Care 2008;31:1679-85). Patients assessed using the protocol should be assigned to a foot risk category from 0 to 3, with 0 being no LOPS, no PAD, and no deformity, 1 being LOPS with or without deformity, 2 being PAD with or without LOPS, and 3 being a history of ulcer or amputation. Therapy and follow-up should be provided according to the category assigned: Primary care monitoring is appropriate for risk categories 0 and 1, and specialist care is indicated for risk categories 2 and 3. Foot examinations “are not done regularly on patients with diabetes,” noted Richard Hellman, MD, one of the study authors and immediate past president of the American Association of Clinical Endocrinologists. The task force report describes in detail how a foot examination can be used in a busy practice setting to identify the foot at high risk for ulceration, Dr. Hellman, an endocrinologist at the University of Missouri-Kansas City, said in an interview. To ensure coordinated care of the diabetic foot, specialists and primary care physicians need to work together, with the specialist brought in early on to focus on prevention, he said. AMDA's clinical practice guideline “Diabetes Management in the Long-Term Care Setting” (www.amda.com/tools/guidelilnes.cfm) includes the following advice: ▸ Assess foot hygiene and foot care practices, including moisturizing, nail cutting, and callus trimming. ▸ Assess for skin and soft-tissue integrity (e.g., active foot infection). ▸ Assess for sensorimotor integrity (numbness) and loss of protective sensation. This assessment may be performed by the practitioner using a 10-g monofilament. ▸ Assess for vascular insufficiency (pedal pulses). Consider ankle/brachia index and noninvasive vascular assessment. ▸ Assess gait and ability to walk. ▸ Inspect foot shape, shoes, and socks. Assess need for protective footwear with accommodative insoles. Medicare may cover therapeutic footwear if medically necessary.