Lower Extremity Assessment · Nail deformities Extensive callus Tineapedis Pitting edema...

www.DiabetesEd.net 1998-2017 Diabetes Education Services©

Lower Extremity Assessment

Beverly Dyck Thomassian, RN, MPH, BC‐ADM, CDE®President, Diabetes Education Services

2017

Objectives:

1. Describe risk factors for lower extremity complications

2. Discuss prevention strategies.

3. Demonstrate steps involved in lower extremity assessment.

4. State 3 diagnostic tools that help assess sensation and blood flow.

Objectives:

Lets take a look at Lower Extremities


Comprehensive Foot Exam

Lower Extremity Complications Combination of vascular, neurological, and musculoskeletal dysfunction

After Lower Extremity Amputation (LEA), people have higher mortality rates and subsequent amputation

Poll Question 1 Which of the following is true about diabetes and lower extremities?A. Over 30% of people with diabetes

experience amputation.

B. Over 50% of amputations could have been avoided.

C. Most amputations happen before the age of 70

D. The rate of amputations is increasing.


Lower Extremity Amputations Dropping over past 10yrs

60% of amputations in 7% of pop

Higher in men, elderly, minorities, Chronic Kidney Disease (CKD)

Lower extremity complications represent 20% of hospitalizations for elderly

Amputations cost $40,000

Amputation associated w/ earlier death compared to revascularization

10 yr survival after LEA

Diabetes and Amputations

Rate declined by 65% from

1996‐2008 From 11.2 per 1000 to 3.9 per 1000

Diabetes = 8 fold risk of amputations

Highest rate in those over 75

50% of amputations can be avoided through self‐care skill education and early intervention

Stats from CDC 2012

Diabetes and Lower Extremity Ulcers

Up to 15% of DM patients have ulcers in their lifetime

Mortality with foot ulcers is twice usual


Poll Question 2 Which of the following factor(s) increase risk for amputation in diabetes?

A. Frequent hypoglycemia

B. Cigarette smoking

C. Previous amputation

D. Foot deformity

Profile of a High Risk Foot ADA Poor glycemic control Peripheral neuropathy Cigarette smoking Foot deformity Preulcerative callus or corn Peripheral arterial disease Previous foot ulcer history Previous amputation Vision impairment Diabetic nephropathy (esp if on dialysis)

Pathway to Amputation – Pecoraro, Frykberg

Minor Trauma (environmental)

+

Faulty Healing (intercurrentpathophysiology: circulation,

WBC/platelet function)

+

Ulceration

Predicts 72% of amp


“I didn’t notice” Needle in foot Pebble in shoe Stepped on a nail Cut too deep Shoes were rubbing

Others?

Poll question #3 What is the most common cause of ulcers?

A. Dr. Scholl’s corn pads

B. Too tight of shoes

C. Trimming calluses

D. Burns from hot water

Common Causes of Ulcers

Tight shoe ‐ 86% is single precipitating event leading to ulcer

Neuropathy and peripheral vascular disease Autonomic: blood pooling, swelling Motor: atrophic musculature, deformity, joint stiffness

Resulting increased plantar pressure, trauma


Pressure Area Breakdown

Neuropathic Diabetes Foot Ulcers

Walking Cast for Neuropathic Ulcers

Emotional aspects

Impact on BG


Foot Deformities

Circulation Issues lead to Lower Extremity Problems

Peripheral Arterial Disease

Vascular Disease

Smoking

Peripheral Arterial Disease Intermittent Claudication

Physical Exam – Skin Pale or blue, purple

Dependent rubor, blanching when elevated

Cool to touch, loss of hair, nonhealing wounds, gangrenous

Diminished pulses

Treatment = Protect feet

Avoid constriction, increase walking, stop smoking, medications and/or surgery


Foot Wounds

Blisters Ulcers Bone infection

Calluses


No Bathroom Surgery

45 years with Type 1 Diabetes

Poll Question 4 Which of the following is a characteristic of peripheral vascular disease?A. Pitting edema

B. Foot blanches on elevation

C. No hair on toes

D. Absent pulses


Peripheral Vascular Disease – Venous Disease

On exam Skin brownish, reddish, mottled

Skin warm to touch, may be edematous

May have stasis ulcers on lower leg

Pulses difficult to locate due to edema

Treatment Support hose, elevate feet, avoid constriction

Shoes that can accommodate feet

Pitting Edema

Venous Ulceration


Diabetes and Charcot Foot

Damaged nerves

Blocked blood vessels

Shifting bones

Collapsed arch joints

Charcot’s• Neurotraumatic theory:

bony destruction due to loss of pain sensation and proprioception + repetitive and mechanical trauma to foot.

• Neurovascular theory:

joint destruction secondary to autonomically stimulated hyperemia and periarticular osteopenia associated with trauma.

45 yr old, type 2 on orals, Random BG 201mg/dl

Tx during acute phase = Casting for 3-6 mo’s then custom footwear

1st Step – Watch Pt Walk


What to Ask in 1 minute Does the patient have a history of: Diabetes – how is control?

Previous leg/foot ulcer or LE amputation

Prior angioplasty, stent or leg bypass surgery

Foot wound that took > 3 wks to heal

Smoking or nicotine use

Does patient have: Burning or tingling in feet

Leg or foot pain with activity or at rest

Changes in skin color or skin lesions

Loss of lower extremity sensation?

Lower Extremities

Lift the Sheets and Look at the Feet

Lower Extremities "Every time you see your doctor, take off your shoes and socks and show your feet!"

For those at high risk for foot complications

All patients with loss of protective sensation, foot deformities, or a history of foot ulcers


What to look for (1 minute) Skin exam Discolored, ingrown, or elongated nails

Signs of fungal infection

Dry or discolored skin, lesions, calluses or corns

Open wounds or fissure

Cleanliness

Interdigital maceration

Neurological Exam Monofilament or Ipswich Touch Test

Tuning fork

Callus and underneath

What to look for (1 minute) Musculoskeletal exam Full range of joints

Obvious foot deformities? If yes, how long?

Midfoot hot, red or inflamed

Vascular Exam Hair growth normal or decreased

Dorsalis pedis and posterior tibial pulses palpable

Temperature difference between calves and feet? Left and right foot?


Flexibility Assessment Stiff joint Syndromes

Biomechanical Foot Assessment –

Test

Plantarflexion & Dorsiflexion of ankles, great toes

Watch pt ambulate

Inspect Shoes

Inspect for deformity

Significant Finding

Diminished joint mobility

Decreased vision, gait imbalance, need for assistive devices

Ability to see/ reach feet

Corn, calluses, bunions, prominent metatarsal heads, hammertoes, claw toes

Foot Deformities


Visual Inspection/Palpation

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

Onychomycosis Chronic Infection 50% of nail problems

We treat on skin but reluctant in nails

Mean duration of > 10 years

Rarely resolves spontaneously

Spreads to other nails, skin, other people

May be source of more serious infections

Affects quality of life

Vicks Vapor Rub?

Foot Exam – Screening for Neuropathy

Test

Semmes‐Weinstein monofilament 10g

Vibration perception threshold testing

Tuning Fork 128 Hz

Significant Finding

Lack of perception at one or > sites

Vibration perception threshold >24 volts

Abnormal vibration perception


Loss of Protective Sensation

Monofilament Testing 5.07 touched to plantar

surface and top of foot

C shape delivers 10 gmspressure

Test four sites

Plantar surfaces of Each great toe1st, 3rd and 5th metatarsal head

5.07 monofilament delivers 10gms linear pressure

10 Free Monofilamentswww.hrsa.gov/hansensdisease/leap/

Monofilament (MF) Procedure(Int Consensus Grp)

Demonstrate procedure on pts forearm or hand

Have pt close their eyes

Test four sites in random sequence

(if callus or ulcer, test adjacent surface)

Bow the MF and ask, “Do you feel it touch you, yes or no?”

Randomly test at each site 3 times (one of which is a “sham” application – MF not applied)


If no monofilament

Tuning Fork to Detect Polyneuropathy

128 tuning fork

Plantar halax

Compare sensation to that of examiner

Back to Basics in Diagnosing Diabetic Polyneuropathy with the Tuning Fork! Meijer, et all Diabetes Care, Vol 28, #9 Sept 2005

Tuning Fork Procedure

On each test: Ask pt to ID beginning of vibration

“Is it vibrating”?

Ask pt to ID cessation by dampening TF.

“Tell me when the vibrating stops”

The number of correct responses = 0‐8

At least 5 incorrect responses = peripheral neuropathy


Foot Exam – Vascular Exam

Test Palpation of pulses dorsalis pedis

tibial

Ankle – Brachial Index (ABI)

Significant Finding Absent pulses

ABI <0.90, consistent w/ peripheral arterial disease

Vascular Status Assessment

Posterior tibial pulse

Dorsalis pedis pulse

Temperature

Appearance

Dorsalis Pedis Pulse


Taking the DP Pulse

Posterior Tibial Pulse

Taking the Posterior Tibial Pulse


Lower extremity systolic pressureBrachial artery systolic pressureABI =

The Ankle‐Brachial Index

Lijmer JG. Ultrasound Med Biol 1996;22:391-8; Feigelson HS. Am J Epidemiol 1994;140:526-34;

Baker JD. Surgery 1981;89:134-7; Ouriel K. Arch Surg 1982;117:1297-13; Carter SA. J Vasc Surg 2001;33:708-14

• The ankle‐brachial index is 95% sensitive and 99% specific for PAD

• Establishes the PAD diagnosis

• Identifies a population at high risk of CV ischemic events

• The “population at risk” can be clinically and epidemiologically defined:

Ankle Brachial Index Technique Measure highest systolic reading in both arms Record first doppler sound as cuff is deflated Record at the radial pulse Use highest of the two arm pressures

Measure systolic readings in both legs Cuff applied to calf Record first doppler sound as cuff is deflated Use doppler ultrasound device

Record dorsalis pedis pressure Record posterior tibial pressure

Use highest ankle pressure (DP or PT) for each leg

Calculate ratio of each ankle to brachial pressure Divide each ankle by highest brachial pressure

Using the ABI: An Example

ABI=ankle-brachial index; DP=dorsalis pedis; PT=posterior tibial; SBP=systolic blood pressure.

Right ABI80/160=0.50

Brachial SBP160 mm Hg

PT SBP 120 mm Hg

DP SBP 80 mm Hg

Brachial SBP150 mm Hg

PT SBP 40 mm HgDP SBP 80 mm Hg

Left ABI120/160=0.75

Highest brachial SBP

Highest of PT or DP SBP

ABI(Normal >0.99)


Interpreting the Ankle‐Brachial Index

Adapted from Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192. Figure 6.

ABI Interpretation

1.00–1.29 Normal

0.91–0.99 Borderline

0.41–0.90 Mild‐to‐moderate disease

≤0.40 Severe disease

≥1.30 Noncompressible

Poll Question 5A patient has a dry skin crack in the back of their heel. What is the best action?

A. Gently scrape the dead skin with a razor

B. Use a pumice stone on area when skin is damp

C. Walk barefoot to promote healing

D. Wear white cotton socks

Foot Care Standards ADA Provide foot care education to pts w/ diabetes

High risk pts – use multidisciplinary approach Wound specialist, Vascular specialist,

Pedorthist etc.

Refer to foot care specialists for lifelong surveillance if: smoke, loss of protective sensation, structural

abnormalities, hx of lower extremity complications

Initial screen for PAD includes: Assess for intermittent claudication and pedal

pulses. Refer high risk pts for further vascular assess

and consider exercise, meds, surgical options.


You Can Make A Difference

Assess Nail condition, nail care, in between the toes

Who trims your nails

Have you ever cut your self?

Shoes – type and how often

Socks

Skin/skin care and vascular health

Ability to inspect

Loss of protective sensation

What to Teach Daily foot care Visual inspection of feet, including in between toes. If pt can’t do this, ask family member for help

Keep feet dry by regularly changing shoes and socks

Report any new sores, discolorations or swelling

Shoes Don’t walk barefoot, even when indoors

Use good fitting footwear

Replace shoes yearly

No Bathroom Surgery


Three Most Important Foot Care Tips

Inspect and apply lotion to your feet every night before you go to bed.

Do NOT go barefoot, even in your house. Always wear shoes!

Every time you see your doctor, take off your shoes and show your feet. Report any foot problems right away!

Thank You

Questions?

Email us at [email protected]

Online Website Diabeteseduniversity.net

Lower Extremity Assessment · Nail deformities Extensive callus Tineapedis Pitting edema...

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