Diabetic Foot Disease

Screening, Assessment and Prescription

William A Munro, Derek Jones

Screening

What is it?Why do it?

The Starting Point for Effectiveness

Screening Is..

Quick & Simple

Assess Patient’s Risk Level

Not the Same asAssessment

What Do We Screen For?

Previous AmputationSignificant deformity

Significant callusActive ulceration

Previous ulcerationVascular insufficiency

Neurological insufficiencyAble to self care?

Low Risk

Moderate Risk

High Risk

Ulcerated

5 % Active Ulcers or Infection - revascularisation or amputationMultidisciplinary management

15 % High RiskIntensive foot protection

20 % Moderate RiskRegular foot protection60% Low Risk

Routine annual screening

Risk Stratification

Patient Information Leaflets

Foot Screening in Scotland

• Detects early disease

• Involves tests that have a predictive value and an agreed cut-off point for referral

• Requires healthcare worker trained for competence in screening

• Does not involve a treatment plan

• Patient does not influence outcome

Screening

Assessment• Establishes a diagnosis

• Involves clinical decision making skills and clinical autonomy for onward referral

• Requires a healthcare professional with the appropriate training/competence in assessment

• Decides on a future management plan

• Patient may influence outcome

• Reassessment is patient-led depending on symptoms or response to therapy

Adapted from Article in DFJ, Vol. 9, No. 4. Mousley, M

• Protection

• Prophylaxis

• Ambulant pressure relief

Purpose of

Shoes

Preventing Trauma MeansControlling the Mechanical

“Environment”

Pressure

Friction

Shear Force

Foot has ..

✓Altered Sensation

✓Altered Tissue Mechanics

✓and Structu

ral Anato

my

Mechanical Challenge

Series ofInterfaces

ExternalForce

SkeletalForce

Ground - Shoe Sole - Insole - Soft Tissue - Bone

Mechanical Challenge

Orthotic Prescription

• Deformity• Significant

• Non-significant

• Ambulation

• Biomechanical

• Neuropathy

• Vascular

• Pain

• Previous Ulceration

• Environment

Biomechanical Assessment• Range of motion

• Deformity

• Flexibility

• Rigidity

• Sensory

Reduced joint mobility leads to elevated plantar pressureSauseng & Kastenbauer

“Diabetic” Shoes

Soft and Roomy

Uppers

We Must Save Money

.. But Who Has the Skills?

How Complicated

Can Shoes Be..?

Pressure Relief?

Rocker Sole?Bespoke or Stock?

Relieve Pressure?

Basic Shoe Function

•Prescription Matrix – Defines function

•Function – Defines Style/Design Possibilities

Footwear Design CriteriaSpectrum of Activity

• Newly screened neuropathic foot

• Moderate Risk

• Non-ulcerated

• Deformed neuro-ischaemic foot

• High Risk• Previous Ulceration

• Shoe and Contact Surface (footbed) Must Work Together

• Materials & Structures Chosen & Positioned for BOTH Control and Tissue Matching

• Shoes Need to act like the “Skeleton” as well as the “Soft Tissues” - Support as well as protect

• “Soft” Uppers not Necessarily Best - Match to the Ambulatory Status and Load Expectations

Fashion Options

Foot Orthoses

• Integral Part of Shoe Design

• Total Contact Orthoses

• Functional Foot Orthoses

• Simple Insoles

• The Foot Orthoses Type Will Impact On The Volume of the Shoe

NO

Due to Complexity of the Situation

You Have to Have Faith - and then build rational processes for

management

Conclusion

• Base on individual patient needs

• Materials to suit the interfaces

• Don’t design the foot orthosis without thinking of the shoe

• Multi-disciplinary education and mutual understanding of orthotic interventions