Between 2010 and 2012, the number of American patients newly diagnosed with diabetes surpassed 3 million.1 In 2012, the direct medical costs of diabetes reached approximately $176 billion.2 Infections and ulcers of the feet are complications often seen in this patient population.3
Since 1988, the number of patients admitted to a hospital with a primary diagnosis of diabetic foot ulcers has steadily increased.4 The lifetime risk of a patient with diabetes having a foot ulcer is 25%, and as much as 50% of older patients with diabetes have two or more risk factors for developing a foot ulcer.5
In 2007, the number of hospital discharges in the United States with a primary diagnosis of a diabetic foot ulcer totaled 113,000-a significant surge from 72,000 in 1988.4 In 2010, 73,000 patients with diabetes underwent nontraumatic lower extremity amputation as a direct result of complications.1 Patients with diabetes account for 60% of all nontraumatic lower amputations.1
Many foot ulcers are preventable.6 Rates of amputation can be decreased by providing foot care education, preventive measures, treatment of foot problems and, if indicated, a referral to a podiatrist.7 A foot exam is a straightforward and inexpensive way to detect wounds, loss of sensation and other abnormalities that may cause complications.5
The American Diabetes Association (ADA)8 has firmly established the importance of performing foot exams and outlined the necessary components. Despite this, many patients with diabetes are not receiving foot exams.6,9 Primary care providers have cited lack of knowledge and comfort with performing a comprehensive exam, along with time constraints and lack of necessary equipment, as reasons why these exams are not completed.6,9
When should foot exams occur?
The ADA7 recommends annual comprehensive foot examination and screening for diabetic peripheral neuropathy for all patients with diabetes. In diabetes patients experiencing numbness or loss of sensation in their feet, and patients with foot deformities or foot ulcers, the ADA recommends performing a foot exam at each visit.8 A referral to a podiatrist is recommended for patients with diabetes who smoke, have a loss of protective sensation, have structural abnormalities, or who have had a lower extremity complication.8
What should be included?
The diabetic foot exam should begin with an in-depth interview that includes a discussion of the following topics: smoking history, previous foot ulcers or amputations, comorbidities, diabetic retinopathy, nephropathy or history of dialysis, and symptoms of neuropathy or vascular symptoms (burning, shooting pain, numbness, claudication or ulcers on the legs).5,8
Next, the NP should closely inspect the feet for dermatologic abnormalities such as calluses or bunions, ulcerations, fungal infections or impaired skin integrity. Musculoskeletal abnormalities should be identified, especially any deformity that may cause increased friction leading to a breakdown of skin or inhibiting full range of motion of the toes. Charcot arthropathy can be identified during this portion of the exam. If the provider sees any symptoms of this condition, such as redness, warmth, swelling or collapse of the arch of the foot, the patient should receive a podiatry referral.5
The neurological portion of the assessment detects loss of protective sensation.5 The NP should use a 10-g monofilament, supplemented by use of a 128-Hz tuning fork, pinprick sensation, ankle reflex or vibration perception threshold testing.5,8 Two normal test results indicate no loss of protective sensation; one or more abnormal test results suggests a deficit.
Nearly one-third of diabetic foot ulcers result from peripheral artery disease, and for this reason, it is also important to assess for posterior tibial or dorsalis pedis pulses.5 If these pulses are negative or the patient reports symptoms associated with vascular complications, such as claudication or nonhealing ulcers, an ankle brachial pressure index should be obtained. If the patient is older than 50, regardless of symptoms, the ankle brachial pressure index testing should be completed because peripheral artery disease is often asymptomatic.5,8
SEE ALSO: Vitamin D and Diabetic Nephropathy
How can exam rates be increased?
Strategies to increase diabetic foot exams in primary care include implementing a standardized charting template providers can use to document the foot exam; adding reminder prompts for other providers; and educating providers about how to conduct a thorough diabetic foot exam in a timely and effective manner. 8,9
Jessica B. Altman recently graduated from the DNP program at the Medical University of South Carolina in the adult gerontology track.
1. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and its Burden in the United States, 2014. http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf
2. CDC report finds large decline in lower-limb amputations among U.S. adults with diagnosed diabetes. http://www.cdc.gov/media/releases/2012/p0124_lower_limb.html
3. Lipsky BA, et al. 2012 Infectious diseases society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):xx.
4. CDC. Number (in thousands) of hospital discharges with peripheral arterial disease (PAD), ulcer/inflammation/infection (ULCER), or neuropathy as first-listed diagnosis and diabetes as any-listed diagnosis United States, 1988-2007. http://www.cdc.gov/diabetes/statistics/hosplea/diabetes_complications/fig1_number.htm
5. Boulton AJ, et al. Comprehensive foot examination and risk assessment: A report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care. 2008;31(8):1679-1685.
6. Cook EA, et al. The amputation prevention initiative. J Am Podiatr Med Assoc. 2014;104(1):1-10.
7. CDC. National Diabetes Fact Sheet: National Estimates and General Information on Diabetes and Pre Diabetes in the United States. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
8. American Diabetes Association. Professional practice committee for the standards of medical care in Diabetes-2015. Diabetes Care. 2014;38(Suppl 1):88-89.
9. Praxel TA, et al. Improving the efficiency and effectiveness of performing the diabetic foot exam. Am J Med Qual. 2011;26(3):193-199.