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Clinical Examination of the Diabetic Foot and Identification of the At-Risk Patient

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Book cover The Diabetic Foot

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Abstract

The most common component in the pathway to amputation is the diabetic foot ulcer (1,2). Although some progress has been made in increasing awareness of the problem of the etopathogenesis of diabetic foot ulceration, much work still needs to be done (3,4). By the end of the first quarter of the present millennium, more than 300 million persons worldwide will have diabetes (5). If we appreciate the fact that, at any one time, up to 7% of at-risk patients with diabetes have a diabetic wound (6) and that most ulcerations are entirely avoidable, the concept of prevention takes on a new urgency. In this chapter, we discuss the key evidence-based risk factors for ulceration, which may be broken down into three practical screening questions to identify patients at highest risk for skin breakdown. We then discuss seven essential questions to answer when both describing and classifying diabetic foot ulceration.

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References

  1. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care 1990;13:513–521.

    Article  PubMed  CAS  Google Scholar 

  2. Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM. Preventive foot care in people with diabetes [see comments]. Diabetes Care 1998;21:2161–2177.

    Article  PubMed  CAS  Google Scholar 

  3. Reiber GE. Diabetic foot care: financial implications and practice guidelines. Diabetes Care 1992;15(Suppl 1):29–31.

    PubMed  Google Scholar 

  4. Reiber GE. Who is at risk of limb loss and what to do about it? J Rehabil Res Dey 1994;31: 357–362.

    CAS  Google Scholar 

  5. King H, Aubert RE, Herman WH. Global burden of diabetes, 1995–2025: prevalence, numerical estimates, and projections [see comments]. Diabetes Care 1998;21:1414–1431.

    Article  PubMed  CAS  Google Scholar 

  6. Abbott CA, Vileikyte L, Williamson S, Carrington AL, Boulton AJ. Multicenter study of the incidence of and predictive risk factors for diabetic neuropathic foot ulceration. Diabetes Care 1998;21:1071–1075.

    Article  PubMed  CAS  Google Scholar 

  7. Lavery LA, Armstrong DG, Vela SA, Quebedeaux TL, Fleischli JG. Practical criteria for screening patients at high risk for diabetic foot ulceration. Arch Intern Med 1998;158: 158–162.

    Article  Google Scholar 

  8. Reiber GE, Vileikyte L, Boyko EJ, et al. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care 1999;22:157–162.

    Article  PubMed  CAS  Google Scholar 

  9. Armstrong DG, Lavery LA, Vela SA, Quebedeaux TL, Fleischli JG. Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration. Arch Intern Med 1998;158:289–292.

    Article  PubMed  CAS  Google Scholar 

  10. Bloom S, Till S, Sönsken P, Smith S. Use of a biothesiometer to measure individual vibration thresholds and their variation in 519 non-diabetic subjects. BMJ 1984;288:1793–1795.

    Article  PubMed  CAS  Google Scholar 

  11. Young MJ, Breddy JL, Veves A, Boulton AJM. The prediction of diabetic neuropathic foot ulceration using vibration perception thresholds. Diabetes Care 1994;16:557–560.

    Article  Google Scholar 

  12. Young MJ, Every N, Boulton AJ. A comparison of the neurothesiometer and biothesiometer for measuring vibration perception in diabetic patients. Diabetes Res Clin Pract 1993; 20:129–131.

    Article  PubMed  CAS  Google Scholar 

  13. Boulton AJ. Guidelines for diagnosis and outpatient management of diabetic peripheral neuropathy. European Association for the Study of Diabetes, EURODIAB. Diabetes Metab 1998;24(Suppl 3):55–65.

    PubMed  Google Scholar 

  14. Kumar S, Fernando DJ, Veves A, et al. Semmes-Weinstein monofilaments: a simple, effective and inexpensive screening device for identifying diabetic patients at risk of foot ulceration. Diabetes Res Clin Pract 1991;13:63–67.

    Article  PubMed  CAS  Google Scholar 

  15. Mueller MJ. Identifying patients with diabetes who are at risk for lower extremity complications: use of Semmes-Weinstein monofilaments. Phys Ther 1996;76:68–71.

    PubMed  CAS  Google Scholar 

  16. Olmos PR, Cataland S, O’Dorisio TM, et al. The Semmes-Weinstein monofilament as a potential predictor of foot ulceration in patients with non-insulin dependent diabetes. Am J Med Sci 1995;309:76–82.

    Article  PubMed  CAS  Google Scholar 

  17. Booth J, Young MJ. Differences in performance of commercially available 10-g monofilaments. Diabetes Care 2000;23:984–988.

    Article  PubMed  CAS  Google Scholar 

  18. Armstrong DG. The 10-g monofilament: the diagnostic divining rod for the diabetic foot? [editorial] [In Process Citation]. Diabetes Care 2000;23:887.

    Article  PubMed  CAS  Google Scholar 

  19. Murray HJ, Young MJ, Hollis S, Boulton AJ. The association between callus formation, high pressures and neuropathy in diabetic foot ulceration. Diabet Med 1996;13:979–982.

    Article  PubMed  CAS  Google Scholar 

  20. Young MJ, Cavanagh PR, Thomas G, et al. The effect of callus removal on dynamic plantar foot pressures in diabetic patients. Diabet Med 1992;9:55–57.

    Article  PubMed  CAS  Google Scholar 

  21. Pitei DL, Foster A, Edmonds M. The effect of regular callus removal on foot pressures. J Foot Ankle Surg 1999;38:251–255; discussion 306.

    Article  PubMed  CAS  Google Scholar 

  22. Collier JH, Brodbeck CA. Assessing the diabetic foot: plantar callus and pressure sensation. Diabetes Educ 1993;19:503–508.

    Article  PubMed  CAS  Google Scholar 

  23. Rosen RC, Davids MS, Bohanske LM, Lemont H. Hemorrhage into plantar callus and diabetes mellitus. Cutis 1985;35:339–341.

    PubMed  CAS  Google Scholar 

  24. Ahroni JH, Boyko EJ, Forsberg RC. Clinical correlates of plantar pressure among diabetic veterans. Diabetes Care 1999;22:965–972.

    Article  PubMed  CAS  Google Scholar 

  25. Boulton AJ, Betts RP, Franks CI, Ward JD, Duckworth T. The natural history of foot pressure abnormalities in neuropathic diabetic subjects. Diabetes Res 1987;5:73.

    PubMed  CAS  Google Scholar 

  26. Duckworth T, Betts RP, Franks CI, Burke J. The measurement of pressure under the foot. Foot Ankle 1982;3:130.

    PubMed  CAS  Google Scholar 

  27. Armstrong DG, Lavery LA, Bushman TR. Peak foot pressures influence healing time of diabetic ulcers treated with total contact casting. J Rehabil Res Dey 1998;35:1–5.

    CAS  Google Scholar 

  28. Cavanagh PR, Ulbrecht JS, Caputo GM. Biomechanical aspects of diabetic foot disease: aetiology, treatment, and prevention. Diabet Med 1996;13(Suppl 1):S17–S22.

    Google Scholar 

  29. Birke JA, Novick ES, Hawkins ES, Patout C. A review of causes of foot ulceration in patients with diabetes mellitus. J Prosthet Orthot 1991;4:13–16.

    Google Scholar 

  30. Grant WP, Sullivan R, Soenshine DE, et al. Electron microscopic investigation of the effects of diabetes mellitus on the Achilles tendon. J Foot Ankle Surg 1997;36:272–278.

    Article  PubMed  CAS  Google Scholar 

  31. Rosenbloom AL, Silverstein JH, Lexotte DC. Limited joint mobility in childhood diabetics indicates increased risk for microvascular diseases. N Engl J Med 1982;305:191–194.

    Article  Google Scholar 

  32. Rosenbloom AL. Skeletal and joint manifestations of childhood diabetes. Pediatr Clin North Am 1984;31:569–589.

    PubMed  CAS  Google Scholar 

  33. Birke JA, Franks D, Foto JG. First ray joint limitation, pressure, and ulceration of the first metatarsal head in diabetes mellitus. Foot Ankle 1995;16:277–284.

    PubMed  CAS  Google Scholar 

  34. Lavery LA, Lavery DC, Quebedeax-Farnham TL. Increased foot pressures after great toe amputation in diabetes. Diabetes Care 1995;18:1460–462.

    Article  PubMed  CAS  Google Scholar 

  35. Frykberg RG, Lavery LA, Pham H, et al. Role of neuropathy and high foot pressures in diabetic foot ulceration [In Process Citation]. Diabetes Care 1998;21:1714–1719.

    Article  PubMed  CAS  Google Scholar 

  36. Fernando DJS, Masson EA, Veves A, Boulton AJM. Relationship of limited joint mobility to abnormal foot pressures and diabetic foot ulceration. Diabetes Care 1991;14:8–11.

    Article  PubMed  CAS  Google Scholar 

  37. Armstrong DG, Stacpoole-Shea S, Nguyen HC, Harkless LB. Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. J Bone Joint Surg [Am] 1999;81A:535–538.

    Article  CAS  Google Scholar 

  38. Birke J, Cornwall MA, Jackson M. Relationship between hallux limitus and ulceration of the great toe. Sports Phys Ther J Orthop 1988;10:172–176.

    CAS  Google Scholar 

  39. Goldner MG. The fate of the second leg in the diabetic amputee. Diabetes 1960;9:100–103.

    PubMed  CAS  Google Scholar 

  40. Armstrong DG, Lavery LA. Plantar pressures are higher in diabetic patients following partial foot amputation. Ostomy Wound Manage 1998;44:30–32, 34, 36 passim.

    PubMed  CAS  Google Scholar 

  41. Quebedeaux TL, Lavery LA, Lavery DC. The development of foot deformities and ulcers after great toe amputation in diabetes. Diabetes Care 1996;19:165–167.

    Article  PubMed  CAS  Google Scholar 

  42. Murdoch DP, Armstrong DG, Dacus JB, et al. The natural history of great toe amputations. J Foot Ankle Surg 1997;36:204–208.

    Article  PubMed  CAS  Google Scholar 

  43. Uccioli L, Faglia E, Monticone G, et al. Manufactured shoes in the prevention of diabetic foot ulcers. Diabetes Care 1995;18:1376–378.

    Article  PubMed  CAS  Google Scholar 

  44. Helm PA, Walker SC, Pulliam GF. Recurrence of neuropathic ulcerations following healing in a total contact cast. Arch Phys Med Rehabil 1991;72:967–970.

    PubMed  CAS  Google Scholar 

  45. International Working Group on the Diabetic Foot. International Consensus on the Diabetic Foot. EASD, Amsterdam, 1999.

    Google Scholar 

  46. Rith-Najarian SJ, Stolusky T, Gohdes DM. Identifying diabetic patients at risk for lower extremity amputation in a primary health care setting. Diabetes Care 1992;15:1386–1389.

    Article  PubMed  CAS  Google Scholar 

  47. Armstrong DG, Lavery LA, Harkless LB. Who’s at risk for diabetic foot ulceration? Clin Podiatr Med Surg 1998;15:11–19.

    PubMed  CAS  Google Scholar 

  48. Steiner G. Diabetes and atherosclerosis; epidemiology and intervention trials, in Atherosclerosis X (Woodford FP, Davingnon J, Sniderman A, eds.), Elsevier, Amsterdam, 1995, pp. 13–93.

    Google Scholar 

  49. Edmonds ME. Experience in a multidisciplinary diabetic foot clinic, in The Foot in Diabetes (Connor H, Boulton AJM, Ward JD, eds.), John Wiley & Sons, New York, 1987, pp. 121–131.

    Google Scholar 

  50. Thompson FJ, Veves A, Ashe H, et al. A team approach to diabetic foot care the Manchester experience. Foot 1991;1:75–82.

    Article  Google Scholar 

  51. Weitz JI, Byrne J, Clagett GP, et al. Diagnosis and treatment of chronic arterial insufficiency of the lower extremities: a critical review. Circulation 1996;94:3026–3049.

    Article  PubMed  CAS  Google Scholar 

  52. Holstein P, Lassen NA. Healing of ulcers on the feet correlated with distal blood pressure measurements in occlusive arterial disease. Acta Orthop Scand 1980;51:995–1006.

    Article  PubMed  CAS  Google Scholar 

  53. Orchard TJ, Strandness DE. Assessment of peripheral vascular disease in diabetes: report and recommendation of an international workshop. Diabetes Care 1993;83:685–695.

    CAS  Google Scholar 

  54. Franzeck UK, Talke P, Bernstein EF, Golbranson FL, Fronek A. Transcutaneous PO2 measurements in health and peripheral arterial occlusive disease. Surgery 1982;91:156–163.

    PubMed  CAS  Google Scholar 

  55. Grayson ML, Balaugh K, Levin E, Karchmer AW. Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients. JAMA 1995;273:721–723.

    Article  PubMed  CAS  Google Scholar 

  56. Birke JA, Novick A, Patout CA, Coleman WC. Healing rates of plantar ulcers in leprosy and diabetes. Lepr Rev 1992;63:365–374.

    PubMed  CAS  Google Scholar 

  57. Reiber GE, Pecoraro RE, Koepsell TD. Risk factors for amputation in patients with diabetes mellitus: a case control study. Ann Intern Med 1992;117:97–105.

    PubMed  CAS  Google Scholar 

  58. Mayfield JA, Reiber GE, Nelson RG, Greene T. A foot risk classification system to predict diabetic amputation in pima indians. Diabetes Care 1996;19:704–709.

    Article  PubMed  CAS  Google Scholar 

  59. Wunderlich RP, Peters EJ, Armstrong DG, Lavery LA. Reliability of digital videometry and acetate tracing in measuring the surface area of cutaneous wounds. Diabetes Res Clin Pract 2000;49:87–92.

    Article  PubMed  CAS  Google Scholar 

  60. Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system: the contribution of depth, infection, and vascular disease to the risk of amputation. Diabetes Care 1998;21:855–859.

    Article  PubMed  CAS  Google Scholar 

  61. Oyibo SO, Jude EB, Tarawneh I, et al. A comparison of two diabetic foot ulcer classification systems. Diabetes 2000;49(Suppl 1):A33.

    Google Scholar 

  62. Armstrong DG, Lavery LA. Diabetic foot ulcers: prevention, diagnosis and classification. Am Fam Physician 1988;57:1325–1332, 1337–1338.

    Google Scholar 

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Authors
  1. David G. Armstrong DPM
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  2. Edward Jude MD
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  3. Andrew J. M. Boulton MD
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  4. Lawrence B. Harkless DPM
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Editor information

Editors and Affiliations

  1. Beth Israel Deaconess Medical Center, Boston, MA, USA

    Aristidis Veves MD, DSc , John M. Giurini DPM  & Frank W. LoGerfo MD ,  & 

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Armstrong, D.G., Jude, E., Boulton, A.J.M., Harkless, L.B. (2002). Clinical Examination of the Diabetic Foot and Identification of the At-Risk Patient. In: Veves, A., Giurini, J.M., LoGerfo, F.W. (eds) The Diabetic Foot. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-59259-168-8_9

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  • DOI: https://doi.org/10.1007/978-1-59259-168-8_9

  • Publisher Name: Humana Press, Totowa, NJ

  • Print ISBN: 978-1-61737-253-7

  • Online ISBN: 978-1-59259-168-8

  • eBook Packages: Springer Book Archive

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