Monafilament testing used in Diabetes Assessment:
Doppler Machine used in Diabetes Assessment:
Diabetes Feet Care in Perth
Here at Foot Focus Podiatry, we have a team of podiatrists dedicated to look after you and your feet should you suffer from diabetes.
It is recommended that every diabetic visit a podiatrist for a detailed diabetes foot assessment every 6-12 months. High risk diabetics should see a podiatrist doctor or a podiatrist every 3 – 6 months according to Diabetes Australia. The aim is to take care of your feet and prevent any problems.
Our podiatrists would be happy to:
- perform a full diabetes foot assessment.
- perform routine nail trimming should you have difficulty reaching your feet or tricky nails to cut (fungal, thickened, or involuted / curvy nail).
- debride any of your hard skin (corns or calluses).
- assess your footwear fitting.
- provide you with education on areas you need to watch out for with your feet and ways to prevent any ulcers – we refer to it as a traffic light assessment of your feet.
If you are worried that you might have an ulcer of the foot, please ring to make an appointment immediately. Our podiatrists David Survepalli and Gaby Tan both work in high-risk hospital setting and specialize in diabetic foot care.
Please read on to learn more about diabetes, how it affects your feet, why it is so important that you see a podiatrist regularly.
Diabetes and Feet
Diabetes is a disease that occurs from having too much glucose in the blood due to the body’s inability to produce or use insulin properly. Diabetes may lead to acute or chronic complications, mainly due to its effect on the blood vessels in the body. In your feet, high blood glucose levels can damage nerves (peripheral neuropathy) and reduce circulation (peripheral vascular disease – PVD). Regular follow up with medical professionals (GP, podiatrist) are recommended to pick up any abnormalities and ensure good and healthy organ function.
Generally, there are two forms of diabetes. Type 1 is also known as insulin dependent diabetes. This is usually diagnosed in children or young adults. People with this type of diabetes usually require daily insulin injections. Type 2 or non-insulin dependent diabetes is by far the most common form and usually affects people over the age of 40 years. It may be managed by modified diet and exercise (diet controlled diabetic) but may also require medication under a doctor’s supervision.
Neurological aspect (your feeling to your feet)
Diabetes is the most common cause of peripheral neuropathy or damage to the peripheral nerve cells and fibres, including sensory nerves, motor nerves, and autonomic nerves. Half of the people with diabetes will develop some degree of neuropathy. Each person has different symptoms which include but are not limited to numbness, burning sensations, pins and needles, and tingling. In most cases, peripheral neuropathy affects the longest nerve fibres first, starting from the furthest part of the body and progresses upwards, causing a “glove and stocking” sensation.
The sensory nerves are responsible for informing the brain of any stimulants, such as stepping on something, the pavement being too hot, or your shoes being too tight. In people with peripheral neuropathy, the stimuli are either reduced or absent altogether, hence preventing individuals from realising that their foot is injured until they see it.
To check for any neurological abnormalities, our podiatrists will do a routine diabetes foot check every 6-12 months depending on your level of risk. At Foot focus podiatry we use certain tools to check different basic sensations.
- Monofilament 5.07 – loss of ability to detect the 10g pressure created by this monofilament is associated with loss of large-fibre nerve function. They are slow adaptors and detect constant pressure and can discriminate the amount of force used. The test is done on the top and bottom of the foot, which indicates areas of risk due to increased plantar pressure in diabetes.
- Vibration test – is done using a 128-Hz tuning fork on the skin above bony prominences. Having vibratory perception deficit or loss of vibration perception is related to an increased risk of diabetic foot ulceration.
- Proprioception – this is the body’s ability to understand body position without having to look. The test is for A-alpha fibres. Loss of proprioception and inability of knowing where one’s feet and toes are, affects stability, balance, and gait.
- Reflex test – tests on the lower limbs are differentiated to deep tendon reflex (done on the knee and ankle) and superficial reflex (bottom of the foot). Reflex text involves some sensory signals and some motor responses ensuring the pathway is intact.
The best way to slow down the progression of diabetic neuropathy is by:
- maintenance of good blood glucose control
- daily visual check of your feet is important as people with reduced sensation may not realise, they have injuries or broken skin
- wearing socks with good fitting shoes is another simple tip to ensure feet are free from unnecessary rubbing or pressure, which may lead to blisters and eventually wounds.
Vascular aspect (how good your circulation / blood supply is to your feet)
Diabetes affects the large and small blood vessels in the body which supply blood to different organs, muscles, and skin throughout the body. This leads to an increased risk of peripheral arterial disease / poor circulation (PVD). Decreased blood flow or circulation to the foot can cause pain in lower limbs, impedes healing, and increases the risk of wound infection. Furthermore, decrease blood flow often causes pain in your leg when walking (intermittent claudication) or during night, usually when lying down in bed (rest pain).
To check for any vascular abnormalities, our podiatrists will do a routine diabetes foot check every 6-12 months depending on your level of risk. At Foot focus podiatry we use certain tools to check for any decrease in blood supply to your feet.
- External indicators – skin condition and presence of hair growth are generic indicators of vascular supply to the feet. Shiny, dry feet with minimal hair growth often found in people with decreased blood supply to their legs and feet.
- Temperature gradient of the lower limbs – your feet should be the coldest part of your lower limb with gradual decrease in temperature.
- Checking for pulses – feet have a few easily palpable pulses that allows the clinician to check for your circulation. Superficial capillary refill time may also be tested in the clinic.
- Doppler machine – a machine that uses reflected ultrasound waves and provides an audible pulse waveform. In a normal state, the arterial pulse forms three clear sounds (triphasic response). Dampened waveform usually indicates disease to your blood vessels.
Decrease in circulation is a result of multiple comorbidities and holistic approach should be taken to improve the circulation. Appropriate exercise according to your fitness level is encouraged to help with the blood circulation. Taking proper medications prescribed by GP and controlling blood sugar, cholesterol and blood pressure are some examples that will decrease any complication due to peripheral artery disease.
The changes in nerve and vascular supply to the foot caused by diabetes, in turn, may lead to deformities causing musculoskeletal conditions of the foot, most commonly involving the forefoot region. These deformities are known to increase the plantar pressure especially around the ball of the foot which can lead to ulceration. One important change that is often overlooked is a deformity known as Charcot arthropathy or “Charcot foot”.
Charcot foot involves the middle part of the foot, where, mostly due to trauma, the arch starts to flatten. It affects diabetic patients with neuropathy and is often presented with a red, hot, swollen foot. Charcot foot has to be treated immediately to minimise arch flattening; failure to do so may lead to “boat shaped” foot, an increase risk of ulceration and bone infection in the area, as well as difficulty in finding shoes and sometimes walking.
When you visit us, we usually check your muscle strength and reflexes to make sure that they are within normal range. Any deformities such as claw/hammer toes, bunion, or Charcot foot will be noted and advise given accordingly.
As the largest organ, your skin’s main function is to act as a barrier against micro-organism, pressure, and environmental elements, on top of regulating body temperature and allowing sensation. Any injury or trauma to the skin will weaken the barrier and may allow micro-organism to enter the body.
People with diabetes often have dry skin which if left unattended, may lead to fissuring in the skin (such as cracked heels) which can be painful. Due to muscle changes and/or skin changes, there is often increased pressure at the bottom of the foot which results in calluses or corn. Often, in people with peripheral neuropathy, besides rubbing from the shoes, these areas of high pressure are where they would develop wounds and ulcers.
To check for your skin status, our podiatrists will usually look for:
- General skin health – dryness, presence of tinea pedis or fungal infection of the skin. These conditions decrease the skin integrity and breakdown may happen easier.
- Redness or hotspots from rubbing with footwear – prolonged rubbing if not alleviated, may cause breakdown and ulceration. Good fitting footwear is important and using simple gel padding or plaster help as well.
- Any skin build-up such as corns or calluses – corns or calluses continue to build up unless the pressure is re-distributed by using, for example, simple padding or orthotics (shoe inserts). Any excessive calluses or corns, if left undebrided may lead to ulceration underneath the hard skin and often overlooked as the overlying skin is still intact.
- Any break in the skin which may lead to ulceration
The best way to maintain skin integrity is by applying emollient to the feet daily, avoiding in-between the toes. Avoid using things such as corn plasters or shaving the calluses by yourself as it increases your risk of the wound. Rather book an appointment to see one of our podiatrists who can help you remove your corns, calluses safely.