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Version 4.0 ANNOTATIONS VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus A. Perform and Document Visual Inspection of Feet OBJECTIVE Examine the patient’s feet for any abnormal findings. RECOMMENDATIONS 1. The patient’s feet should be visually inspected for: [I] • Breaks in the skin • Erythema • Trauma • Pallor on elevation • Dependent rubor • Changes in the size or shape of the foot • Nail deformities • Extensive callus • Tinea pedis • Pitting edema DISCUSSION Despite limited information, there is consensus in the diabetes professional community (including ADA), that visual inspection combined with peripheral sensation testing may identify some unsuspected lesions in patients with diabetes. This practice also demonstrates to the patient the importance of foot assessment. EVIDENCE Recommendation Sources LE QE SR 1 Visual inspection of the feet at ADA, 2002 III Poor I every routine primary care visit. Working Group Consensus LE-Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A) B. Perform Foot Risk Assessment OBJECTIVE Identify the patient at risk for LE ulcers and amputations. RECOMMENDATIONS 1. A foot risk assessment must be performed and documented at least once a year. A complete foot risk assessment includes: • Evaluation of the skin for breakdown • Assessment of protective sensation using the Semmes-Weinstein 5.07 monofilament • Evaluation for LE arterial disease • Evaluation for foot deformity • Prior history of ulcers or amputations In addition, the patient’s footwear should be evaluated. DISCUSSION Patients with diabetes are at risk for developing peripheral neuropathy with loss of sensation. Patients, who develop peripheral vascular disease or end stage renal disease, are considered high-risk for developing a foot ulcer. Protective and prophylactic foot care and early detection of any deformity or skin breakdown may prevent the Module F – Foot Care Page 97
Version 4.0 VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus development of ulcers and risk of amputation. The tensile strength of mature scar tissue is about 80 percent of original tissue strength, thus increasing the chance of developing further ulceration. The patient should therefore be questioned about foot ulcer history. A person who has had a foot ulcer is at life-long risk of further ulceration. evidence Recommendation Sources LE QE SR 1 Foot risk assessment. ADA, 2002 Mayfield et al., 1998 Mayfield et al., 2000 III II II Fair B LE-Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A) C. Are Any Limb-Threatening Conditions Present? OBJECTIVE Identify a limb-threatening condition that may require immediate attention, referral, or hospitalization. RECOMMENDATIONS 1. Evaluation should be performed for limb-threatening conditions, such as systemic infection, acute ischemia/rest pain, foot ulceration, puncture wound, ingrown toenail, and hemorrhagic callus with or without cellulitis. Discussion Systemic or Ascending (Worsening) Infection Limb-threatening conditions could include signs and symptoms of systemic infection including gas gangrene, ascending cellulitis and lymphangitis, or gangrene. Although infection is not always clinically apparent, common signs and symptoms include perilesional warmth, erythema, purulent drainage, odor, and involvement of bone. Pain may or may not be present. There may or may not be lymphangitis and lymphadenopathy, and fever and white blood cell count may or may not be present. Sudden loss of glycemic control often heralds serious infections (Orchard, 1993). Acute Ischemia or Rest Pain Absence of palpable pedal pulses - Examine the patient to determine presence of dorsalis pedis and posterior tibial pulses. Absent pulses and signs of acute ischemia, e.g., rest pain associated with dependent rubor with pallor or palpably cold extremities, warrant urgent referral to a vascular surgeon. Acute ischemia or rest pain – Evidence of arterial insufficiency: lower limb pain at rest, dusky/blue or purple/black color, gangrene, or cold extremity. Pain in the toes or forefoot may be relieved by dependency of the limb. Assessment is needed for prompt vascular/surgical intervention. Patient with acute arterial occlusion will present with pain, pallor, pulseless, paresthesia, and/or paralysis (Orchard, 1993). Claudication - Severe claudication is determined as pain in the thigh or calf that occurs when walking less than one block and is relieved by rest. Peripheral vascular diseases are associated with diabetic bilateral amputation. Preventative foot care programs should focus on peripheral vascular assessment to identify patients at risk and on the development of timely intervention strategies (Carringtonl. et al., 2001). Foot Ulceration Active foot ulcer - Cutaneous erosion with a loss of epithelium that extends to or through the dermis can involve deeper tissue and is characterized by an inability to self-repair in a timely and orderly manner (ADA, 2002; Brodsky & Schneidler, 1991; Caputo et al., 1994; Eckman et al., 1995; Reiber et al., 1995). Puncture Wound Module F – Foot Care Page 98
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