High Risk Diabetic Foot Evaluation

Diagnosis/Definition

• High risk diabetic foot is a general term used to describe a variety of foot problems related to diabetes mellitus.
• These complications range from skin fissures to large non-healing ulcers that commonly originate from shoe blisters, corns, or unidentified trauma and may potentially lead to amputation.
• Other factors that contribute to diabetic foot complications include: peripheral neuropathy (light touch, motor and autonomic), deep or superficial infections, structural changes and deformities (i.e., hammertoes, bunions, areas of callous, boney prominence, rheumatoid nodules, Charcot joint), arterial and venous insufficiency, traumatic foot or ankle injury or presentation of a foreign body.

Initial Diagnosis and Management

Risk Factors:

• History of vascular disease or revascularization procedure
• History of lower extremity ulcer and/or lower extremity infection
• History of partial foot/toe amputation
• Symptoms of claudication
• Symptoms of peripheral neuropathy
• Burning, tingling, numbness, or hyperesthesia
• Night pain
• Absent sensation in part or entire foot to include distal leg
• Inability to find shoes which fit
• Physical assessment of the foot to include:
• Presence of ulceration
• Presence of skin fissures
• Presence of ingrown/infected toenail
• Presence of excessive callus, corns , blisters
• Absence of pedal pulses
• Loss of protective threshold diagnosed with monofilament and vibratory testing
• Presence of foot deformity
• Compromised skin integrity
• Compromised nutritional status
• Unstable gait
• End stage renal disease
• Signs of lower extremity infection
• Pallor of lower extremity on elevation and rubor of lower extremity on dependency
• Maceration within digital web spaces
• History of Charcot foot (See Charcot Foot Referral Guideline)

Ongoing Management and Objectives

To decrease the rate of toe, foot, and lower extremity amputation in the diabetic population with prompt referral of active ulceration and those patients at high risk for developing ulceration to a group of specialists who focus on mechanical, medical, and surgical intervention in the treatment of the diabetic foot.

Indications for Specialty Care Referral

• Patients with any of the following should be referred to the Wound and Ostomy Clinic:
• Any diabetic patient with ulcerations, signs of infection, traumatic injury, presence of a foreign body or suspected Charcot should be referred to Orthopedics and Wound and Ostomy Clinic ASAP. Please call first: 433-3445 Ms. Lum in Wound and Ostomy Clinic. Orthopedics on Call - 576-8900 or Staff Podiatrist: 577-7495.
• All diabetics regardless of age and associated risk should be referred to Wound and Ostomy Clinic for an annual evaluation/screening in clinic 433-3445.
• Patients with a combination of one or more of the signs and symptoms identified in the Initial Diagnosis and Management above should be referred as potential high risk.
• All Retiree's, VA and dependents with foot conditions 30, 31, 01, 02, 03, 04 etc.. Respectfully need to be routed to Schofield Barracks Podiatry or net worked out for treatment. Tripler Podiatry unfortunately does not provide orthotics or inserts for dependents, VA or Retiree's.

Criteria for Return to Primary Care

• After any acute problem has been appropriately treated.
• Patients found to be at high risk for foot ulcerations should be followed in the Limb Preservation Service at intervals determined by the clinic providers in conjunction with the Primary Care Provider. These follow-up intervals will change based upon the progression or regression of the complications identified in each specific patient.
• All patients should be followed by the primary care provider for treatment of all co-morbid conditions and routine care with the goal of optimal health and wellness for the whole patient.