The Diabetic Foot
Original Editor - Tarina van der Stockt
- 1 Introduction
- 2 Specific Foot Conditions
- 3 Assessment
- 4 Management / Interventions
- 5 Resources
- 6 Case Studies
- 7 References
Complications in the diabetic foot are mostly caused by a triad of ischemia, diabetic neuropathy, and infection. 
Statistics about the impact of diabetic foot complications:
- Foot ulcer complications are the main reason why people with diabetes are hospitalized and have to undergo amputations.
- 20-40% of all the health care costs comprised for diabetes are for diabetic foot complications
- 7-10% of patients with diabetes and neuropathy will develop an ulcer; this increases up to 30% for patients with diabetes and other comorbidities.
- 5-8% of patients will undergo a major amputation 1 year after developing a diabetic ulcer.
- A foot ulcer preceded 85% of diabetes related amputations.
- “Diabetes increases the risk of amputation 8-fold in patients aged >45 years,8 12-fold in patients aged>65 years and 23-fold in those aged 65––74 years.”
Specific Foot Conditions
Diabetic NeuropathyDue to diabetic neuropathy patients do not have the protective sensation in their feet. Thus the patient will not feel any trauma, like stepping
Diabetic Foot Ulcers and Delayed Wound Healing
- In the diabetic foot peripheral arterial disease (PAD) is seen as the primary cause for vascular impairment.
- The risk of developing PAD is increased with diabetes and ischemia is considered the biggest culprit delaying wound healing.
- Diabetic neuropathy and ischemia combined is called neuroischemia. In these cases the wound healing is affected by the severity of the ischemia.
- Diabetes Mellitus and Diabetic Ulcers
Diabetic Foot Infections
- The most common sign is increased ulcer exudation rate.
- Diabetic foot infections may lead to poor glycemic control. 
- There is a 50% delay in diagnosing deep foot infections in diabetes patients because the infection markers in their blood tests are found absent. 
- Infections in a diabetic foot can rapidly spread to the rest of the body and if not treated properly could lead to a life-threatening general septic infection 
Diabetic Foot (Charcot foot/joint)
They may present with:
- muscle weakness in the feet, ankles, legs and hands
- an awkward way of walking (gait)
- highly arched or very flat feet
- numbness in the feet, arms and hands
More information available from Charcot-Marie-Tooth Disease - NHS Choices (2012).
Clinical Examination according to Lep¨antalo et al. 
- General (Medications, diseases, cardiovascular risk factors, work, hobbies, lifestyle, diabetes symptoms/complications
- Foot specific (risk factors and information about present ulcer – duration, treatment, aetiology)
- Inspection (at least once a year)
- Dorsalid Pedis Pulse
- Tibialis posterior pulse
- Venous refilling time - >5sec on dependency
- Foot appearance
- 10-gram (5.07) Semmes––Weinstein monofilament
- Vibration(128 Hz-tuning fork)
- Pinprick discrimination and tactile sensation on the dorsum of the foot
- Achilles tendon reflexes
- Observe for foot deformities or bony prominences
- Ulcer – look for perfusion, extent and size, and infection
- Local signs and symptoms of inflammation: purulent secretion, redness, warmth, swelling, pain, delayed healing, and or bad odor.
- Systemic signs: fever, and poor general condition
- Increased exudation in the ulcer
- X-rays to determine the presence of foreign bodies, gas, osteomyelitis, osteolysis, or joint effusion
- MRI, bone scan or CT scan to determine the extent of the infection
- Non-invasive vascular studies
- Ankle pressure
- Ankle-brachial systolic pressure index (ABI) (<0.6indicates significant ischemia in respect to wound healing)
- Toe pressures (<30 mmHg indicates severely impaired healing)
- Vascular imaging
- Sub-talar ROM (any reduction may increase plantar pressures during walking) 
Management / Interventions
- Physical Therapists are involved in both the prevention and management of diabetic foot complications.  This is done by gait, posture, and foot off-loading education and training.
- Diabetes Medical and Physical Therapy Management
- Charcot Foot Medical Management
- Charcot Foot Physical Therapy Management
- Charcot Foot Medical and Physical Therapy Management
- Diabetic Neuropathy Management/Intervention
- The Physical Therapist is also involved in the rehabilitation process after an amputation.
- Patient education
- In a 2009 evidence-based literature review, the authors found that TENS might be effective for pain treatment in diabetic neuropathy.
- The authors of a 2008 control study of 30 neuropathic diabetic patients concluded that as part of the multidisciplinary approach physical therapy plays an important role in the treatment of diabetic neuropathic patients. 
They used the following adjunct on the treatment group every day for twelve weeks:
- Low level laser irradiation for 10-15 minutes/session on the ulcer
- Laser biostimulation on the peroneal nerve trunk (at the fibula head) at 1000 Hz for 15 minutes
- Specific dorsiflexion and ankle ROM exercises
- Education on foot care and home exercises
- Diabetic Wound Care Management. "> BEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS
- Antibiotic treatment is indicated in all infected wounds in combination with wound care, until the infection is cleared up.
- Hospitilisation, immobilisation, and IV antibiotics are indicated for limb threatening or uncontrolled infections.
- Urgent surgery is indicated if the infection is "accompanied by a deep abscess, extensive bone or joint involvement, crepitus,
substantial necrosis or gangrene, or necrotising fasciitis." Lepäntaloa et al. recommend that "surgical intervention for moderate or severe infections is likely to decrease the risk of major amputation."
These articles are recommended for further in depth reading on the subject:
- Lepäntaloa M, Apelqvistc J, Setaccie C, Riccof JB, de Donatoe G, Beckerg F, Robert-Ebadig H, Caoh P, Ecksteini HH, De Rangok P, Diehml N. Chapter V: Diabetic Foot. European Journal of Vascular and Endovascular Surgery. 2011;42(S2):S60-74
- Pedrosa HC, Leme LA, Novaes C, Saigg M, Sena F, Gomes EB, Coutinho A, Borges Carvalho WJ, Boulton A. The diabetic foot in South America: progress with the Brazilian Save the diabetic foot project. International Diabetes Monitor. 2004;16(4):17-23.
- Turan Y, Ertugrul BM, Lipsky BA, Bayraktar K. Does physical therapy and rehabilitation improve outcomes for diabetic foot ulcers?. World journal of experimental medicine. 2015 May 20;5(2):130.
- Amputation secondary to Diabetes Mellitus: Amputee Case Study
- A 35 year old diabetic Aboriginal women, who underwent a right transtibial amputation for diabetic foot ulcer and completed prosthetic rehabilitation.
- Diabetic patient amputation: Amputee Case Study
- Diabetic complications leading to amputation: Amputee Case Report
- Diabetic Patient with Bilateral Amputations : Amputee Case Study
- The Young, Diabetic Amputee: Amputee Case Study
- Bilateral Below Knee Amputation due to Diabetic Complications: Amputee Case Study
- Lower Limb Amputation: Diabetic Case Presentation: Amputee Case Study
- Older Diabetic Amputee with slow healing: Amputee Case Study
Follow this link to read more case studies.
- Lepäntaloa M, Apelqvistc J, Setaccie C, Riccof JB, de Donatoe G, Beckerg F, Robert-Ebadig H, Caoh P, Ecksteini HH, De Rangok P, Diehml N. Chapter V: Diabetic Foot. European Journal of Vascular and Endovascular Surgery. 2011;42(S2):S60-74.
- Zakaria HM, Adel SM, Tantawy SA. The Role of Physical Therapy Intervention in the Management of Diabetic Neuropathic Foot Ulcers. Bull. Fac. Ph. Th. Cairo Univ. 2008 Jul;13(2).
- Youtube Video: The Diabetic Foot Exam https://youtu.be/aVz-Ja9Grvg
- Kalra S, Kalra B, Kumar N. Prevention and management of diabetes: the role of the physiotherapist. Diabetes Voice. 2007;52 (3)
- Dubinsky RM, Miyasaki J. Assessment: Efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review) Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2010 Jan 12;74(2):173-6.