Welcome : Welcome
Diabetic Foot UlcerRole of Physiotherapist : Diabetic Foot UlcerRole of Physiotherapist T. Senthilkumar M.P.T (Ortho).,M.I.A.P
Asst. Professor
Shanmuga College Of Physiotherapy
What is Diabetes Mellitus? : What is Diabetes Mellitus? Diabetes Mellitus is a group of metabolic disorders characterized by high levels of blood glucose resulting from defects in insulin production, or action, or both.
Types of Diabetes : Types of Diabetes Type 1
Type 2
Gestational Diabetes
The Need : The Need India has the largest number of diabetic patient (19.4 Million) - 1995
In 2025 this is projected as 57.2 million ie 114.4 million foot are at risk
40 – 70%- All lower extremity amputation are related to diabetes mellitus
85% - All diabetic related amputation are due to foot ulcers.
30 sec - Every 30 sec a leg is lost to diabetes somewhere in the world
One in every six people with diabetes will have an ulcer during their life time. Ratio (1:6) Source: WHO Statistics on Diabetic Foot Ulcer
Contd.. : Contd.. 45% of diabetics will have peripheral vascular disease after 20 years
After first below –knee amputation 42% of patients with lose the contra lateral limb within 1 year
11-40% of patients will die within first year of their below-knee amputations Source: WHO Statistics on Diabetic Foot Ulcer
The term diabetic foot has been coined to encompass a multitude of leg / foot presentation where the underlying disease is Diabetes Mellitus. : The term diabetic foot has been coined to encompass a multitude of leg / foot presentation where the underlying disease is Diabetes Mellitus. Diabetic Foot ?
Clinical triads : Clinical triads Peripheral neuropathy
Peripheral vascular disease
Mechanical factors (deformities)
Anatomy of the Foot : Anatomy of the Foot 26 – bones + (2-sesamoids) = 28
57- Joints
42- Muscles
107- ligaments
In lifetime, its is estimated that a human being walks about 100,000m(1,50,000 KM) equaling to almost 4 times around the world
Why PVD & Peripheral Neuropathy is common in lower limbs than in upper limbs : Why PVD & Peripheral Neuropathy is common in lower limbs than in upper limbs A comparative lengthening of lower extremity
Internal rotation to render the foot planti-grade
Weight bearing got restricted to two instead of four limbs
Our ability to see our plantar decreased significantly
Great toe went further away from the body so its needs longest nerves and arteries
Bio & Patho mechanics of Diabetic Foot : Bio & Patho mechanics of Diabetic Foot
Phases of Gait Overview : Phases of Gait Overview Stance phase (62%)
Contact period - heel contact (HC) to forefoot contact (FFC)
Midstance period - forefoot contact (FFC) to heel off (HO)
Propulsion period - heel off (HO) to toe off (TO)
Swing phase (38%)
early swing, late swing, double and single support
Normal Foot Function : Normal Foot Function Heel Strike
The foot assists in shock absorption. The foot and leg are required to be a loose chain structure. Mid Stance
The foot supports the entire body. A stable structure is required Propulsion
The foot is required to adapt to the needs for propulsion. A rigid lever is required
Normal Foot Function contd.. : Normal Foot Function contd.. Heel Strike - Subtalar joint pronates and allows shock absorption
Mid Stance – Subtalar joint comes to neutral position and acts as stable structure
Propulsion – Subtalar joint supinates and acts as rigid lever
Abnormal Foot Function : Abnormal Foot Function
Slide 17: Sensory loss
Trauma / Pressure / Stress / Heat
Blisters /
Wound
Ulcer
Tissue loss Autonomic dysfunction
Dryness
Cracks / Fissures / Callous
Ulcer
Tissue loss Motor Paralysis
Altered biomechanics
Contractures/Pressure/ blister/ wounds
Ulcer
Tissue Loss PAD
Ischemia
Ulcer
Infection
Tissue Loss
Factors affecting normal biomechanical loading in diabetic foot : Factors affecting normal biomechanical loading in diabetic foot Deformities
Abnormal walking pattern
Limited joint mobility
Repeated plantar pressure
Shear stress
PATHOGENESIS OF ULCERATION OF DIABETIC FOOT : PATHOGENESIS OF ULCERATION OF DIABETIC FOOT Impulse loading in diabetic neuropathy is very high at 1st MTP joint
Increasing ground contact time due to LJM, soft and connective tissues changes, already existing deformities and scars of previous ulcers
Due to autonomic neuropathy the recovery from anoxia and ischemia is delayed as the sympathetic denervation of the circulatory bed occurs
This causes increased warmth and Erythema in the region of 1st/3rd/5th metatarsal heads
This leads to progressive inflammation and exudates formed
Continued walking with blisters promotes ulcers formation in the risk areas
Commonest deformities in diabetic foot : Commonest deformities in diabetic foot FLAT FEET (OVER PRONATION OF FEET)
PES CALCANEUS
PES EQUNIUS
CLUB FOOT
INSUFFICIENT PUSH OFF
ACHILLES TENDINITIS
PLANTAR FASCITIS
HALLUX ABDUCTO VALGUS (BUNION)
HALLUX RIGIDUS
METATARSALGIA
HAMMER TOE
CALLUSES
High risk areas of diabetic foot : High risk areas of diabetic foot 1st Metatarsal Head
2nd and 3rd Metatarsal Head
Between 4th and 5th MT Head
Ball of the all toes
Under 1 MTP joint
Under MTP joints
Lateral heel
CAUSATIVE FACTORS FOR NEUROPATHIC ULCERS : CAUSATIVE FACTORS FOR NEUROPATHIC ULCERS EXTRINSIC FACTORS
Ill fitting footwear
Barefoot walking
Falls/accidents
Objects inside shoes
Thermal trauma
Injury by sharp objects
Home surgery INTRINSIC FACTORS
Limited joint mobility
Bony prominences
Foot deformities
Neuro-arthropathy
Plantar callus
Scar tissue
Fissures
Clinical features of diabetic foot : Clinical features of diabetic foot SIGNS OF MOTOR NEUROPATHY
Clawed toes
Raised arch of foot
Foot drop
Intrinsic muscle wasting
Other deformities SIGNS OF AUTONOMIC NEUROPATHY
Dry skin
Fissuring
Distended dorsal veins
Warm foot
Increased blood flow
Bounding pulses
Various Presentations of diabetic foot : Various Presentations of diabetic foot Fissures
Abscesses
Cellulitis
Ulcers
Gangrene
Claw Toes
Charcot foot
Wagner ulcer classification system : Wagner ulcer classification system
Role of Physiotherapy : Role of Physiotherapy
“The Whole problem is really one of mechanics not of Medicine”- Dr Paul Brand : “The Whole problem is really one of mechanics not of Medicine”- Dr Paul Brand
Assessment and Investigations : Assessment and Investigations History
Neurological Examination (sensory)
Foot Biomechanical Assessment
Wound assessment
Radiological Examination
Pedobarography
F - Scan
Examinations : Examinations 1. Touch and pressure - Semmes Weinstein Nylon Monofilament 10gm
2. Vibration Perception Threshold (VPT)- by tuning fork
3. Thermal thresholds i.e. sensation of heat and cold
4. Foot pressure measurements by pedobarograph
5.Reflex assessment by using tendon hammer
Foot Functional Assessment : Foot Functional Assessment Ask the patient to walk on the spot for a few seconds.
Ask the patient to stop, stand still and look straight ahead.
Look at the heel to see it turns in or out. Normal Heel Everted Heel Inverted Heel
Interventions : Interventions Prevention
Therapeutic Exercises
Health Education & Home care activities
Splinting
Modalities
Footwear
Orthosis
Prosthesis
Prevention and Education : Prevention and Education Proper education about insensitive foot
Regular examination of the sole of the foot
Immediate reporting if there is any change in sensory perception or motor abnormality
Checking nails for blood flow or any discoloration
Check feet regularly for blood circulation, and blisters, callus, corns, wound
Contd…. : Contd…. Soak the feet for 20-30 minutes in cold water to keep the foot supple and smooth (especially those who have fissures and cracks)
Dress the wound properly
Give adequate rest to the affected part
Avoid long distance walking
Wear Proper Footwear
Aim of physiotherapist in diabetic foot clinic : Aim of physiotherapist in diabetic foot clinic To control and maintain blood glucose level
To check the area at risk of foot ulcers and give utmost care to that risky areas
To educate the foot care and prevention methods
To advice proper footwear
To educate do’s and don'ts during daily activities properly
Contd.. : Contd.. To advice proper foot splints
To minimize neuropathic pain
To prevent deformities
To improve muscle power and prevent muscle wasting
To increase range of motions, strength, endurance
To prevent limited joint mobility
Means : Physiotherapy can help people to maintain good blood glucose control and achieve optimal weight
Isotonic exercise like jogging, running, walking will benefit a person with diabetes
LMJ mobility is corrected by teach active exercise to toes and foot
Neuropathy pain to be corrected by the TENS and Interferential therapy
HVPC (High voltage pulsed galvanic current) also used to enhance wound healing
Electrical stimulation will enhance wound healing Means
Contd.. : Exercise - Burger-Allen exercises will facilitate and activate the blood circulation in lower extremities
To teach Off Loading techniques that means train crutch walking, wheel chair training
During off loading its necessary to prevent muscle wasting by active physio for leg & foot muscles
To identify the excessive pressure areas and advice suitable foot wears
To concentrate the dry skin to avoid that advice soaking training in cold water Contd..
Objectives of diabetic foot wear : Objectives of diabetic foot wear Relief of excessive plantar pressure
Reduction of shock
Reduction shear (frictional forces)
Accommodation of minimal deformity
Stabilization of deformity
Preventing recurrence of ulcer
: Total contact Cast is the appropriate way of resting the foot with diabetic plantar ulcer
It Distributes weight along the entire plantar aspect of the foot.
It Reduces shear forces normally present between the foot and shoe.
It Produces shortened stride length and a decreased walking velocity. Splinting
Various types of Rocker Soles : Various types of Rocker Soles Mid rocker soles – to relieve pressure metatarsal
Heel to toe rocker soles – fixed claw toes, hammer toes, calcaneal ulcers
Toe only rocker soles – ulcer metatarsal heads
Severe angle rocker sole – hallux rigidus, ulcer on the distal part of toe, hammer toe, ulcer metasal heads
Negative heel rocker sole – fixed ankle in dorsiflexion
Do’s : Do’s Inspect the feet daily using mirror (especially b/w toes, pressure areas)
Wash feet daily water
Apply lotion, oil to feet after drying
Avoid extremes of temperature
Have your feet checked at each clinic visit
Inspect shoes daily for defects/foreign bodies
Change shoes often
Regular skin and nail care
DONT’S : DONT’S Walk barefoot
Smoke
Step into the bath before checking water temperature
Use heating pads
Perform bathroom surgery
Use chemical agent to treat corns or calluses
Wear new shoes for more than an hour at a time
Conclusion : Conclusion Physiotherapist are likely to treat patients
for diabetes related complications. Therapist
may also have a role in preventing
complications secondary to diabetes. So we are
the peoples more responsible to treat and prevent
the diabetic foot ulcers for diabetes patients
“PREVENTION IS BETTER THAN CURE”
Thank You : Thank You