Checking the feet of diabetes patients may be some of the most effective wound care a nurse can provide. FIONA CASSIE finds out more about how to prevent and detect the early signs of foot ulcers that can see people losing toes, feet and even legs.
But for people with diabetes these experiences may mean they are just a few numb and unfeeling steps away from a diabetic foot ulcer. And for some those steps could be taking them down the path to losing toes, a foot or even a lower leg.
The International Diabetes Federation reports that every 20 seconds somebody with diabetes has a limb amputated.
Statistics from New Zealand’s Artificial Limb Service show that people with diabetes have gone from making up 24 per cent of new amputees each year to 38 per cent of new amputees (174 people) in less than a decade. And that doesn’t include toes.
Sadly, it is estimated that 85 per cent of all amputations caused by diabetes are preventable if foot complications like diabetic foot ulcers are detected and treated early.
It is also estimated that 15 per cent of the more than 257,000 people in New Zealand with diabetes will have a foot ulcer in their lifetime – that percentage is stable but the number of people getting diabetes is not, so the number needing specialist foot and wound care keeps growing.
Foot screening: “notoriously poorly done”
Michele Garrett is a diabetes specialist podiatrist at Waitemata District Health Board providing such specialist foot care.
She says an unfortunate reality of today’s “flat out and full on” general practice is that annual diabetes foot checks are “notoriously poorly done”.
“Some anecdotal data tells that only about 40 per cent are done and some other audits show that between 30–60 per cent of people with diabetes get an annual foot screen when it is meant to be everybody.”
Garrett says there are multiple factors influencing the poor statistics including patients not liking showing their feet, the doctor or nurse doing the screening not liking feet and sometimes feeling pushed for time to get the person to take their shoes and socks off. “It is amazing how many foot screens get done with footwear still on.”
She says health professionals can’t just ask people with diabetes about their feet – they have actually got to see the feet.
“You must remember that neuropathy or numbness is a major contributing factor to foot problems,” says Garrett. “People will say that their feet are okay but very few foot ulcers are identified by the patient – quite often they are only identified at opportunistic screenings because numbness meant the person was unaware.”
Garrett was part of the New Zealand Society for the Study of Diabetes podiatry team that developed the 2014 diabetes foot screening and risk stratification tool. The tool is built on the Scottish guideline, but with the addition of Māori ethnicity as a risk factor to reflect the much higher risk of amputation experienced by Māori with diabetes (see link in resources next page).
The latest international guidelines recommend on top of the annual diabetes foot screen that all people with high risk feet or neuropathy should have their feet checked each time they see a health professional. This is because people with numb feet may not have pain “as their friend or indicator” that something is wrong. Also obesity, age, vision impairment and other factors sees some people struggle to adequately care for or check their feet.
Bare feet and jandals – the Kiwi attitude to feet
Kiwis also typically think their feet are ‘tough’.
Garrett recently undertook some qualitative research looking at how growing up ‘Kiwi’ influenced the attitudes of people with diabetes towards their feet.
“All of them went barefoot as children and didn’t wear special footwear for sport and grew up with a real ‘she’ll be right’ attitude to their feet,” says Garrett.
The most people did was “dab a bit of Dettol” on a cut or a blister, but once people have diabetes such cursory first aid is not enough as a simple cut can quickly become a major issue for people with a moderate to high risk of diabetes foot ulcers.
Garrett says people with diabetes need to be told not only how to take good care of their feet but also why and the what if consequences of activities like walking barefoot on a black sand beach on a hot summer day with numb feet through neuropathy. :
Regular foot screening is key
The annual diabetes foot screen provides an opportunity for just such patient education as well as detecting any new risk factors or spotting active or potential ulcers.
Garrett says a good foot screen can be a simple process needing only your eyes and fingers and taking just a few minutes.
With their fingers nurses can check the pulses in the feet for signs of vascular problem. Also, if a nurse doesn’t have a 10g monofilament on hand for the neurological test, they can just use their fingers instead to carry out the Ipswich touch test to assess for loss of sensitivity to the toes (see link in resources sidebar).
After asking the set questions on the NZSSD foot screening checklist, the screening process is finished with a visual inspection of the feet for callouses, redness, blisters, cuts or ulcers.
Depending on the screening results, the response can range from patient education and self-management for the low risk foot through to referral to a podiatrist for the moderate to high-risk foot.
For people with active foot disease most regions have some form of specialist diabetes foot clinic that people can be urgently referred to, with clinics often working in conjunction with a district nursing service, says Garrett.
She says it is imperative with foot ulcers to offload the pressure on the foot by putting people in special surgical shoes, moon boots or casts. “It is the constant pressure (on the foot) combined with the diabetes that inhibits ulcers healing.”
Rapid referral to a specialist service with the right offloading strategies in place can see ulcers heal relatively quickly and stop them progressing to complex chronic wounds that are much more time-consuming to heal. It also reduces the risk of amputations.
Foot screening is not only important in primary health settings but also if a person with diabetes or neuropathy is admitted to hospital, because of the increased risk of pressure injuries on their heels and the bottom of their feet, says Garrett.
Also people with neuropathy may be allowed to wander around the ward in bare feet and socks when they should be wearing special footwear.
Urgent hospital admission is needed for people found to have severe or spreading infection or critical ischaemia.
Garrett hopes that regular screening, education and rapid referral can help more Kiwis with diabetes work through their ‘she’ll be right’ attitude to their numb feet and see fewer face chronic ulcers or risk amputations.
SEE RELATED STORY: Diabetic foot case studies
People at risk of foot ulcers
- People with type 1 or 2 diabetes (particularly if poorly controlled).
- Anyone who has had peripheral vascular disease.
- People with neuropathy (often causing loss of sensation in the feet).
- People with previous ulcers or amputations or Charcot Foot are seen as particularly high risk.
How to reduce risk of diabetic foot ulcers
- Keep diabetes well controlled.
- Good diabetes foot care education from time of diabetes diagnosis.
- Annual diabetes foot screening of low-risk patients by suitably trained nurse or health professional.
- More frequent screening of moderate to high-risk feet during patient’s three-monthly visits (particularly if they have a loss of sensation) plus an annual assessment by
- a podiatrist and a mutually agreed treatment plan.
- Check footwear is fitting well, with no pressure points, and has cushioned soles.
Foot care fast facts
- Cushioned sole footwear is key for reducing pressure on the bottom of the foot.
- Diabetes New Zealand advises people to go for comfort not style, with broad fitting sports or walking shoes a good choice.
- Special orthotic insoles can help reduce pressure on the feet and in some situations subsidised orthotic shoes are available.
- Choose new shoes wisely – suggest wearing for 20–30 minutes (either in the shop or arranging to trial at home) and then examine feet to see whether there are any reddened patches or other signs that the shoe is causing pressure or a hot spot.
- Shoes shouldn't be 'broken in' as the only thing that 'breaks' are feet.
- If person has calloused or ingrown toenails, a specialist podiatrist should trim nails to reduce risk of nicks and infections.
- If feet are cracked or dry, use an appropriate moisturiser, particularly in areas that can split.
Diabetes New Zealand
Diabetes & Your Feet
The New Zealand Wound Care Society
Diabetic Foot Assessment Forms
New Zealand Society for the Study of Diabetes (NZSSD)
Diabetes foot screening and risk stratification tool
Podiatry New Zealand
Advice on when to see a podiatrist
Ipswich Touch Test
A ‘touch the toes’ sensation test