The Bangalore Hospital
202, R.V.Road - Bangalore 560 004.
Management of foot in a patient with diabetes mellitus starts with the first encounter of the patient whether there is a foot lesion or not. Careful and detailed inspection and examination of all parts of foot and footwear and preventive foot care instructions should form part of guidelines during the initial and then every visit.
In the absence of complication it is not uncommon to find fissures, ingrowing toe nails, epidemophytosis and superficial lesions due to ill fitting footwear. They are all potential port of entry for infection. Instruction must be given to prevent these lesions or get them treated.
With sensation and good blood supply being intact trivial lesions generally heal promptly with good control of diabetes, debridement with or without antibiotics.
Eight percent of all admissions (230 patients) in a three year period at the Bangalore Hospital had foot lesion. This does not include outpatients with minor foot lesions. The age of these subjects ranged from 31-96 years. The majority were in the 5th and 6th decade. Male were 152 and female were 78. Duration of DM ranged from 10-20 years. Eight of these were on diet. 96 on oral hypoglycemic agents (OHA), 120 on insulin and six on insulin and OHA.
|Neuropathy was present in the majority||132 (57%)|
|Vascular insufficiency||37 (16%)|
|None of the above||61 (27%)|
|A few had both neuropathy and peripheral vascular disease (PVD) in varying degree.|
Lesions start at pressure points - plantar aspect of heads of metatarsal (MT), great toe, heal, base of the 5th MT etc; corn, callouses, blisters, foot wear bite and site of entry of foreign body often get infected.
The lack of pain and awareness result in extensive spread along the muscle fasia to deeper and higher levels resulting in cellulitis and high pressure within the tissues often causing destruction of soft parts and bones requiring emergency surgical procedures.
Is vulnerable to trauma, infection, tissue destruction and gangrene. The level of vascular occlusion can most often be determined by careful palpation of arterial pulsation. Doppler study for arterial blood flow with ankle and toe pressure recordings and arteriography are helpful to know the extent of problem, and plan therapy / procedure.
Include arterial reconstruction, with or without amputation of the part involved and this depends on presence or absence and the extent of gangrene.
Aspirin is sometimes useful in the presence of thrombosis. Occasionally embolisation and intra arterial ballooning help to relieve arterial occlusion. Vasodilator drugs have no place.
Usually seen in ankle and tarsal bones in the presence of peripheral sensory and motor neuropathy. Weight bearing becomes difficult in these patients. They often need amputation.
Management of foot lesions is not complete without making the patient walk and return to work with proper and individually designed foot wear with microcellular leather insole and soft leather or Kangora rubber all-round.
|Improved with conservative (medical and debridiment) management||165 (72%)|
|Required surgical procedure||57 (25%)|
|Lost to followup / dead||8 (3%)|
|Arterial reconstruction 8 (successful 6).|
|Amputation at various levels in 36, more often in an infected neuropathic foot/limb.|
The cost of management of limb or life threatening lesion whether in a neuropathic or ischemic foot ranges from Rs. 25,000 to 75,000. The time and effort required at considerable and often taxing to the patience of patients, family members and medical profession.
Therefore preventure measures assume great importance.
|Paraesthesia||no (0)||yes (2)|
|Hypoesthesia||no (0)||yes (4)|
|Anaesthesia||no (0)||yes (6)|
|Veins on dorsum of foot|
|Empties normally on lying flat (0)|
|Distended on lying flat (3)|
|Distended on leg elevation to 45 (6)|
|H/O intermittent claudication||No (0)||Moderate (3)||Severe (6)|
|H/O rest pain||No (0)||Moderate (3)||Severe (6)|
|H/O nocturnal leg pain||No (0)||Moderate (3)||Severe (6)|
|Peripheral Pulses||Normal (0)||Feeble (4)||Absent (6)|
|Filling time after blanching of nail beds|
|By pinching (in seconds)||<5 (0) 5-10 (1) 11-15 (2) . 15 (4)|
|Skin and Nail Changes:|
|Improper carefoot wear||Yes (1)|
|Skin: cold/dry/thickened/atrophic/shining/loss of hair||No (0)||Yes (2)|
|Nails: thickened /ingrown/fungal infections||No (0)||Yes (2)|
|Presence of corns||No (0)||Yes (2)|
|Presence of calluses||No (0)||Yes (2)|
|Deformaties of toes & foot|
|Based on the points scored, patients are classified into categories A to E with increasing risk for developing foot problems.|
|A <5: B 5-10: C 11-15: D 15-20: E . 20:|
1. Patients in categories C,D and E require intensive foot care education and corrective therapy is possible.
2. Patients should be evaluated every six months; if the number of points increases, need for evaluation for increase and corrective measures.
3. A history of a previous foot problem puts a patient in the high risk category irrespective of points scored.