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2018 Clinical Practice Guidelines

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Foot Care NA
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Chapter 32
John M. Embil MD FRCPC FACP, Zaina Albalawi MD FRCPC,
Keith Bowering MD FRCPC FACP, Elly Trepman MD
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2018 Diabetes Canada CPG – Chapter 32. Foot Care

2018
Key Changes
• New information on
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• Detailed instructions on use of theY 10 gram
ONpresence or
monofilament to screen forEthe
US
absence of protective sensation
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RS
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2018 Diabetes Canada CPG – Chapter 32. Foot Care

Foot Care Checklist

EDUCATE about proper foot care
EXAMINE for structural, vascular, neuropathy
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problems
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DO a 10 gram monofilament assessment
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IDENTIFY thoseSat N
O high risk of foot ulcers and
E R
P more frequently, and
educate, assess
consider appropriately fitted footwear
REFER persons with foot ulcers and other
complications to those specialized in foot
care
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People with Diabetes are 20X More Likely to be
Hospitalized for Non-traumatic Limb Amputation

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Public Health Agency of Canada (August 2011); using 2008/09 data from the Canadian Chronic Disease Surveillance System (Public Health Agency of Canada).

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2018 Diabetes Canada CPG – Chapter 32. Foot Care

Prevention through education

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Proper risk Lassessment
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Early andP aggressive treatment

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Educate People with Diabetes on Proper Foot Care
– The “DO’s”
DO …
Check your feet every day for cuts, cracks, bruises, blisters, sores, infections, unusual
markings
Use a mirror to see the bottom of your feet if you can not lift them up

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Check the colour of your legs & feet – seek help if there is swelling, warmth or redness
Wash and dry your feet every day, especially betweenO
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S E the toes

L Uand soles. Wipe off excess

Apply a good skin lotion every day on your heels
N A
Change your socks every day
S O
Trim your nails straight across R
P E
Clean a cut or scratch with mild soap and water and cover with dry dressing
Wear good supportive shoes or professionally fitted shoes with low heels (under 5cm)
Buy shoes in the late afternoon since your feet swell by then
Avoid extreme cold and heat (including the sun)
See a foot care specialist if you need advice or treatment

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Educate People with Diabetes on Proper Foot Care
– The “DON’Ts”
DO NOT …

Cut your own corns or callouses, nor treat your own in-growing toenails or slivers with a
razor or scissors. See your doctor or foot care specialist
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Use over-the-counter medications to treat corns and warts
O N
Apply heat with a hot water bottle or electric blanket E
U S – may cause burns unknowingly

A
Soak your feet or use lotion between your toes L
O N
Take very hot baths
R S
P
Walk barefoot inside or outside E
Wear tight socks, garter or elastics or knee highs

Wear over-the-counter insoles – may cause blisters if not right for your feet
Sit for long periods of time
Smoke

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2018 Diabetes Canada CPG – Chapter 32. Foot Care

How to Perform Proper Foot

Examination
• Skin changes
Structural • Evidence of infection
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• CallousY or ulcer
Abnormalities
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• E Range of motion
US• Charcot foot
A L
Peripheral O N
R S • Temperature
Arterial PE • Skin changes
Assessment • Ankle Brachial Index

Neuropathy • 10 gram monofilament

Assessment

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2018 Diabetes Canada CPG – Chapter 32. Foot Care

Key Elements of the Lower Extremity Physical Examination

Element Parameter
Inspection • Gait
• Foot morphology (Charcot arthropathy, bony prominences)
•
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Toe morphology (clawtoe, hammertoe, number of toes)
• L
Skin: blisters, abrasions, calluses, subkeratotic hematomas
N
O
or hemorrhage, ulcers, absence of hair, toe nail problems,
E
edema, abnormal color
• Status of nails U S
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• Foot hygiene (cleanliness, tinea pedis)
O N
R S
Palpation •
•
E
P (increased or decreased warmth)
Pedal pulses
Temperature
Protective • Sensation to 10 gram monofilament
sensation
Footwear • Exterior: signs of wear, penetrating objects
• Interior: signs of wear, orthotics, foreign bodies

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 Screening for Protective Sensation Using The
10 gram Monofilament
How to perform the sensory
examination:
• Conduct in a quiet and relaxed
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setting.
•ONBegin by applying the
SE monofilament to the hands,
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NA elbow or forehead so that
O patient what to expect.
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• Ensure that the patient can not
see whether or where the
monofilament is being applied.
• Test the three sites on both feet
shown in the figure.

Modified from: Schaper NC, Van Netten JJ, Apelqvist J, Lipsky BA, Bakker K; International Working Group on
the Diabetic Foot. Prevention and management of foot problems in diabetes: A Summary Guidance for
Daily Practice 2015, based on IWGDF Guidance Documents. Diabetes Metab Res Rev 2016;32 PERSONAL
Suppl 1:7-15
USE ONLY
 Screening for Protective Sensation Using
The 10 gram Monofilament
Apply the monofilament B Apply sufficient force to cause the
A perpendicular to the skin surface filament to bend or buckle

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How to Apply the monofilament:
• Repeat the application twice at the same site, but alternate the application with
at least one ‘mock’ application in which no filament is applied (total three
questions per site).
• Protective sensation is present at each site if the patient correctly answers two
out of three applications. Incorrect answers – the patient is then considered to
lack protective sensation and is at risk of foot ulceration.
Modified from: Schaper NC, Van Netten JJ, Apelqvist J, Lipsky BA, Bakker K; International Working Group on
the Diabetic Foot. Prevention and management of foot problems in diabetes: A Summary Guidance for
Daily Practice 2015, based on IWGDF Guidance Documents. Diabetes Metab Res Rev 2016;32 PERSONAL
Suppl 1:7-15
USE ONLY
2018 Diabetes Canada CPG – Chapter 32. Foot Care

Who is at High Risk of

Developing a Foot Ulcer?
• Peripheral neuropathy
• Loss of protective sensation using
Y 10 gram
monofilament N L
E O
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• Previous ulceration or amputation
A L
N
O or limited joint mobility
• Structural deformity
R S
P E
• Peripheral arterial disease
• Microvascular complications
• Elevated A1C
• Onychgryphosis

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2018 Diabetes Canada CPG – Chapter 32. Foot Care

When Should a Foot Exam be

Performed?

Low Risk LY
• Annually
O N
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L • More frequent
High risk
NA
for ulcer SO e.g. Every 3-6 months
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Foot ulcer • Refer to an
present interprofessional team
with expertise in foot
ulcers

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2018 Diabetes Canada CPG – Chapter 32. Foot Care

Foot Ulcer: Interprofessional Team

Approach
• Foot care education
High risk L Y
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for ulcer •SEProfessionally-fitted
L U footwear
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SO
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PE • Prompt referral to
If ulcer
interprofessional
develops
team with expertise
in foot ulcers

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2018 Diabetes Canada CPG – Chapter 32. Foot Care

University of Texas Diabetic

Wound Classification System
Stage Grade
0 I LIIY III
O N
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A (no Pre- or post-
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Superficial wound Wound Wound
infection or
N A
ulcerative lesion not involving penetrating penetrating

epithelialized SO
ischemia) completely tendon, capsule, to tendon to bone or
R or bone or capsule joint
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B Infection Infection Infection Infection
C Ischemia Ischemia Ischemia Ischemia
D Infection and Infection and Infection Infection
ischemia ischemia and and
ischemia ischemia

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2018 Diabetes Canada CPG – Chapter 32. Foot Care

Recommendation 1
1. Health-care providers should perform foot
examinations to identify people with diabetes at risk for
ulcers and lower-extremity amputation
L Y [Grade C, Level 3] at
least annually and at more frequent O N intervals in high-
S
risk people [Grade D, Level 4]. TheEexamination should
include assessment for:AL
U
• Neuropathy, O N
R S
• Skin changes E
P (e.g., calluses, ulcers, infection),
• Peripheral arterial disease (e.g., pedal pulses and
skin temperature),
• Structural abnormalities (e.g., range of motion of
ankles and toe joints, bony deformities) [Grade D,
Level 4]

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2018 Diabetes Canada CPG – Chapter 32. Foot Care

2018
Recommendation 2
2. People with diabetes who are at high risk of
developing foot ulcers should receive foot care
education (including counselingN toLY
avoid foot
E O footwear [Grade
trauma) and professionallySfitted
D, Consensus]. L U
N A early referral to a health-
2
SO
• When foot complications occur,
R
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care professional trained in foot care is recommended [Grade
C, Level 3]

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2018 Diabetes Canada CPG – Chapter 32. Foot Care

Recommendation 3
3. People with diabetes who develop a foot ulcer or
show signs of infection even in the absence of
pain should be treated promptly L Y an
by
O N
interprofessional health-care SE team (when
available) with expertiseLinUthe treatment of foot
N A foot ulcers and
ulcers to prevent recurrent
SO
ER C, Level 3]
amputation [Grade
P

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2018 Diabetes Canada CPG – Chapter 32. Foot Care

Recommendation 4
4. There is insufficient evidence to recommend any
specific dressing type for typical diabetic foot
ulcers [Grade C, Level 3]. L Y
N O A, Level 1A] and
• Debridement of nonviable tissueE[Grade
USinclude the provision of a
general principles of woundLcare
NA environment, and off-
physiologically moist wound
SOD, Consensus]
loading the ulcer [Grade
R
PE

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2018 Diabetes Canada CPG – Chapter 32. Foot Care

Recommendation 5
5. There is insufficient evidence to recommend the
routine use of adjunctive wound-healing
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therapies (eg. topical growth factors,Y granulocyte
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colony-stimulating factors, orSEdermal substitutes),
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for typical diabetic foot ulcers.
A
• Provided that all otherO N
modifiable factors (e.g. pressure
R S foot deformity etc) have been
P E
offloading, infection,
addressed, adjunctive wound-healing therapies may be
considered for non-healing, non-ischemic wounds [Grade A,
Level 1].

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2018 Diabetes Canada CPG – Chapter 32. Foot Care

Key Messages
• In persons with diabetes, lower extremity
complications are a major cause of Y morbidity
and mortality N L
EO
U S
• The treatment of foot ulcers in people who
L
A a interprofessional
N
have diabetes requires
O
R S
approach that addresses glycemic control,
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infection, off-loading of high-pressure areas,
lower-extremity vascular status, and local
wound care

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2018 Diabetes Canada CPG – Chapter 32. Foot Care

Key Messages
• Antibiotic therapy is not required for
LY
uninfected neuropathic footNulcers
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• Proprietary adjunctive Swound dressings
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and technologies N A
including antimicrobial
dressings lack R SO
sufficient evidence to
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support their routine use in the treatment of
neuropathic ulcers

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2018 Diabetes Canada CPG – Chapter 32. Foot Care

Key Messages for People with

Diabetes
• Diabetes can cause nerve damage (also known as
diabetic peripheral neuropathy) andLY poor blood flow
O
or circulation to the legs and feet N known as
(also
peripheral arterial disease)US
E
AL
• As a result of neuropathy,
O N people with diabetes are
S
less likely to feelEaRfoot injury, such as a blister or cut.
P
Diabetes can also make these injuries more difficult
to heal. Unnoticed and untreated, even small foot
injuries can quickly become infected, potentially
leading to serious complications

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2018 Diabetes Canada CPG – Chapter 32. Foot Care

Key Messages for People with

Diabetes
• A good daily foot care routine will help keep your feet
healthy. L Y
O
• Examine your feet and legs daily N
S E
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• Care for you nails regularly
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• Apply moisturizing N A
O lotion if your feet are dry
S
• Avoid lotion E R
between the toes
P
• Massage well, minimize residue
• Wear properly fitting footwear
• Test your bath water with your hand before you
step in, to make sure the water is not too hot

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2018 Diabetes Canada CPG – Chapter 32. Foot Care

Key Messages for People with

Diabetes
• Do not treat any of the following yourself, rather,
have them treated by your doctor or L Yother foot care
ONpodiatrist or
specialist (such as foot care nurse,
chiropodist): SE
U L
•
N
Corns (thick or hard skin Aon toes)
S O
•
R
Callouses (thick skin on bottom of feet)
• PE
Ingrown toenails
• Warts, splinters, or other wounds
• If you have any swelling, warmth, redness or pain in
your legs or feet, see your health-care provider or
foot specialist right away

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Visit guidelines.diabetes.ca

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Or download the App

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Diabetes Canada Clinical
Practice Guidelines

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www.guidelines.diabetes
.caE O
N
U– Sfor health-care
AL providers
O N
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PE 1-800-BANTING (226-
8464)

www.diabetes.ca – for
people with diabetes

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