DIABETES AND THE DIABETIC FOOT EXAM QUESTIONS AND ANSWERS 2024.

What are the 3 mechanisms of diabetic damage to the Foot? 1. Diabetic Peripheral Neuropathy (DPN) - AGE products destroy the vasculature that feeds the nerves of the Foot and as a result the nerves die or decay, resulting in insensate foot. As a result of nerve decay sensation and proprioception are lost. This denies the sensation of pain and allows abnormalities/damage to occur that are unrealized. Any issues that develop after this begins are unsensed. This process is irreversible once begun but can be slowed with glucose control and medications. Remember, Diabetes, "loves," to attack small blood vessels. 2. Neuroarthropathy - This is a change in the bony structure of the foot that can result in a deformed foot ("Lockerbottom Foot" or, "Charcot Foot") 3. Peripheral Vascular Disease - Vascular damage by AGE products and poor glucose uptake/energy production results in poor vasculature that fails to perfuse the foot well. This compounds problems, slows healing, and predisposes the foot to structural disintegrity that increases the likelihood of damage. What is the end result of these 3 mechanisms? - The end result of these processes is ulceration, which leads to infections, which ultimately lead to amputations. A Note on the 3 Mechanisms - Remember, 3 mechanisms and 3 results: 1. DPN -> Insensate foot 2. Osteoarthropathy -> Deformed foot 3. PVD -> Poorly perfused foot What are the risk factors for DPN? In other words, what circumstances increase the likelihood of developing DPN? - Hyperglycemia - Insulin Deficiency - Smoking (*ulcers are incapable of healing*) - BMI - Hypertension How does DPN manifest on the body? Where does it attack first? - DPN manifests at the feet before the hands and progressively worsens in the distal to proximal direction. This is described as a, "stocking and glove" distribution What else can cause neuropathic symptoms similar to those caused by DPN? - Alcoholism - Vitamin B12 (Cobalamin) deficiency (secondary to its effects on the posterior column of the spinal cord) How do Symptoms and Signs differ? - Symptoms are a SUBJECTIVE and PATIENT DERIVED description of the condition, disease, or injury. - Signs are OBJECTIVE INDICATORS FOUND ON PHYSICAL EXAM What are the symptoms of PVD? - Claudication - Claudication is defined as leg pain and cramping with activity What are the signs of PVD? - Poikilothermia - Thinning of the skin of the feet and legs - Loss of hair on the skin of the feet and legs - Thickening of the nails - Ulcers - Delayed healing What are the risk factors for ulceration generally? In other words, what behaviors or conditions increase the likelihood of developing diabetic ulcers. - PND (loss of sensation and thus loss of notice for injury) - Foot Deformity or osteoarthropic foot (improper distribution of pressure) - PVD (poor waste product removal, poor nutrient delivery, thus, increase in cellular metabolic disorder) - Tobacco smoking (decreased capacity for healing) - Poor glycemic control (increased AGE product production) - Vision impairment (increased likelihood of trauma, falls, etc) - DN - Previous foot ulcer or amputation (process is likely already aggressive) Are diabetic patients predisposed to foot infections? If so, why? - Diabetic patients are predisposed to a variety of infections (bacterial, fungal, etc) - Patients are disposed to infections because: 1. Hyperglycemia facilitates microbial growth and reduces leukocyte activity 2. PVD/poor perfusion decreases the oxygen available to cells that need it for energy production (healing, growth) What are the ADA Standards concerning foot care for patients with Diabetes? 1. Annual comprehensive foot exams 2. Visual inspection of the feet at EVERY visit with a clinician for patients with known neuropathy What are the components of the Comprehensive Foot Exam? 1. Inspection 2. Assessment of pedal pulses 3. Testing for loss of protective sensation, including: a. Vibratory testing b. Monofilament testing c. Reflex testing at the Ankle How is reflex testing performed? What reflex is tested? - The Ankle Jerk reflex is tested at the Achilles' Tendon (S1) - The foot is dorsiflexed and the reflexes are graded as 0-4 where: 0 = absent 1 = diminished 2 = normal 3 = hyperreflexia 4 = hyper refelexia with clonus