office-based screening, prevention, and management of diabetic foot disorders

Prim Care Clin Office Pract

34 (2007) 873–885

Office-Based Screening, Prevention, andManagement of Diabetic Foot Disorders

Daniel C. Farber, MDa,*, Jerry S. Farber, MDb,c

aDepartment of Orthopaedics, University of Maryland School of Medicine,

2200 Kernan Drive, Baltimore, MD 21207, USAbPrivate Practice, 2415 Musgrove Road, Silver Spring, MD 20904, USA

cDepartment of Orthopaedics, Georgetown University, 4000 Reservoir Road,

Washington, DC 20057, USA

Diabetic foot disorders are common conditions in the diabetic populationthat can in large part be prevented. Diabetes affects 5% to 10% percent ofthe US population [1], and those patients have a 12% to 25% lifetime risk ofdeveloping a foot ulcer [2,3]. Once patients develop an ulcer, they carrya 10% to 30% chance of progressing to an amputation [4]. Diabetic patientsaccount for 50% of the nontraumatic lower extremity amputations in thiscountry [5]. These problems result in substantial expenditure of healthcare dollars and time, affecting patients’ quality of life. Because of these con-siderable effects on the population as a whole and the potentially devastat-ing effects diabetic foot problems can wreak upon an individual, screening,prevention, and treatment for them is critical in primary health care deliv-ery. The increasing prevalence of diabetes in the United States makes iteven more important to focus on preventative measures. These strategies,as well as screening and basic treatment, are well within the ability and scopeof the primary care physician.

There exist a number of challenges to the treatment of diabetic foot prob-lems. Very commonly, patients are in denial of their disease, and this is oneof the greatest difficulties to overcome. A patient who refuses to help him orherself cannot be successfully managed by screening and prevention. Eventhose patients well aware of their disease are often noncompliant with thesometimes labor-intensive self-treatment involved in overall diabetic care.In a properly motivated patient, maintaining appropriate, healthy glucoselevels is crucial, and can be accomplished by diet, exercise, or medication.

* Corresponding author.

E-mail address: [email protected] (D.C. Farber).

0095-4543/07/$ - see front matter � 2007 Elsevier Inc. All rights reserved.

doi:10.1016/j.pop.2007.07.001 primarycare.theclinics.com

mailto:[email protected]

http://www.primarycare.theclinics.com

874 FARBER & FARBER

Patients are often challenged to find physicians able to provide the appropri-ate care and follow-up required for successful disease management. Last,patients need to be constantly and consistently educated about their disease,its consequences, and its treatment.

To properly execute a prevention program, the etiologies of diabetic footproblems must be understood. A critical triad of neuropathy, repetitivetrauma, and deformity exists [6]. The primary problem in the diabeticfoot is neuropathy. Diabetic neuropathy may affect sensory, motor, or au-tonomic pathways, and is generally insidious in onset. Peripheral neuropa-thy is extremely common in patients who have diabetes (over 50% inpatients age 60 and over [7]), and may be manifested by changes beginningbefore the diagnosis of diabetes to several years after diabetes managementhas been instituted. The onset may be recognized by the patient as a sense ofnumbness, tingling, or other paresthesias or night pain in one or both feet.Sensory disturbances are often noted in a ‘‘stocking and glove’’ distribution.Microvascular disease creates chronic ischemic changes within the periph-eral neural fibers leading to the progression of neuropathy. Although thediscomfort may begin as a sensory phenomenon that manifests as increasedsensitivity (hyperalgesia) and pain, the progression of the disease often leadsto complete insensitivity of one or both feet. Without proper education, pa-tients are unaware of the potential for foot problems. This loss of sensationprevents patients from protecting the foot from harmful elements. These caninclude pressure from ill-fitting shoes, improper footwear, objects on theground or in a shoe, extreme heat or cold, and other noxious stimuli. Auto-nomic dysfunction can lead to dry skin, with cracks or fissures that mayserves as entry portals for bacterial infections in the compromised foot. Mo-tor neuropathy may also affect diabetics, and may be evident by the devel-opment of claw toes caused by intrinsic muscle dysfunction or an Achillescontracture. These changes transfer stress to the forefoot, leading to in-creased pressure in these areas, and thus they increase the potential forbreakdown and ulceration both on the plantar metatarsal heads and dorsalproximal interphalangeal joints (hammertoe).

The diabetic foot may be less able to defend itself secondary to the vas-cular disease prevalent in diabetics. Changes in the vascular anatomy thataccompany diabetes include deposits of platelets, lipids, cholesterol, and cal-cium in the vessel linings, creating a gradual lack of perfusion in the diabeticfoot. Large vessel disease is present when the distal pulses are diminished orabsent, and changes consistent with decreased circulation occur throughoutthe leg. Small vessel disease is more insidious, but will still have a significanteffect upon ulcer healing, despite palpable distal pulses. These effects canmake it more difficult to effectively fight infection with systemic antibiotics,and in more extreme cases, may lead to sepsis or gangrene.

Effective care of the diabetic foot requires screening to detect the at-riskfoot, prevention to avoid the occurrence of ulcers, and treatment to heal ulcersquickly before they become more significant problems. Also important to

875MANAGEMENT OF DIABETIC FOOT DISORDERS

recognize and properly address is the Charcot process that may occur withoutwarning signs in patients who have been compliant with a treatment regimen.

Screening

Screening of diabetic patients is a crucial step in prevention. Warningsigns can be found in multiple systems, most importantly the vascular andneurologic areas, but dermatologic and medical surveillance may also pro-vide clues to underlying susceptibilities. Several studies [2,8,9] have demon-strated that an effective screening program can reduce foot ulcers andcomplications, thereby improving the quality of life for diabetic patients.Successful screening involves patient questioning for behavior risks, physicalexamination, and validated screening tests. Screening allows the determina-tion of patient risk and aids in further treatment and screening (Table 1).

Behavior screening

Behavior screening consists of focused questioning to assess whether pa-tients are following appropriate preventative measures. Patients should beasked about type and fit of shoe-wear, as well as the use of materials onthe foot such as cotton or synthetic material socks, over-the-counter salves,and bunion or hammertoe cushions. Risky behaviors such as barefoot walk-ing, hot or cold water soaks, and infrequent cleaning or inspection of thefeet should be elicited. This is often a good opportunity to assess what pa-tients know about proper foot care and hygiene, as opposed to simply deliv-ering a stock lecture on foot care.

Physical examination

Physical examination consists of a visual inspection, palpation of thefoot, vascular and neurologic assessment, dermatologic assessment, motorexamination, and determination of range of motion of the foot and ankle.Performing these examinations on an ongoing and recurrent basis canlead to early and effective treatment and decrease the potential foramputation.

Visual inspection includes assessing the overall appearance of the foot.Multiple areas of healing injuries, bruising, or skin disturbances provideclues about current at-risk behaviors. Obvious deformities, such as bunions,hammertoes, a rocker bottom foot, or Achilles contracture should be as-sessed for potential high-pressure areas that may result in skin breakdown.Vascular skin changes such as stasis dermatitis, skin atrophy, hair loss, nailchanges, or clear areas of decreased perfusion are important to note and fol-low. Inspection of the patient’s shoes for appropriateness, fit, and potentialareas of pressure as well as signs of skin injury (bloody or other drainage)may yield helpful information.

876 FARBER & FARBER

Table 1

Risk categories for foot complications

Category Risk factors Treatment recommendations

0 No history of ulceration

No deformity

No previous amputation

Pedal pulses present

No sensory loss

Instruct in basic foot care

Yearly foot examination

Regular footwear


No deformity

No previous amputation


Sensory loss

Daily foot self-examination

Diabetic foot patient education

Depth shoes or running shoes

Nonmolded soft inlays

Possible total contact orthoses

Foot examination by physician every

6 months


Moderate (prelesion) deformity

(ie, hallux rigidus, metatarsal

head prominence, claw or

hammer toes, callus, plantar

bony prominence, hallux

valgus, or dorsal exostosis)


Single lesser ray amputation

Sensory loss


Diabetic foot patient education

Depth shoes or running shoes

Custom-molded foot orthoses

Adjuncts: silicon toe sleeves, lambs wool,

foam toe separators, hammer toe crests,

or metatarsal pad

External shoe modifications: metatarsal

bar, rocker sole, extended steel shank,

or medial or lateral wedges

Foot examination by physician every

4 months

3 History of ulceration

Presence of deformity (ie, Charcot

deformity, hallux rigidus,

metatarsal head prominence,

claw or hammer toes, callus,

plantar bony prominence, hallux

valgus, or dorsal exostosis)

Previous amputation (multiple ray,

first ray, transmetatarsal, or

Chopart)

Pedal pulses present or absent

Sensory loss


Patient-at-risk diabetic foot education

Custom-fabricated, pressure dissipating

accommodative orthoses

Inlay-depth, soft-leather, adjustable-lacing

shoes

External shoe modifications: rocker soles,

extended steel shanks, solid ankle

cushion heels, well filled with

low-density materials

Unweighting orthoses (patella tendon

bearing brace, ankle-foot orthoses)

Foot examinations by physician every

2 months

Immediate clinical evaluation of any new

skin or nail problem

Consider evaluation by orthopaedic foot

and ankle surgeon

Patients are assigned a risk category (0 to 3) based on the likelihood of foot complications.

Factors considered in each category include history of ulceration, presence or absence of defor-

mity, previous amputation (partial or full) of either foot, presence or absence of pedal pulses,

and degree of sensory loss (neuropathy).

From Berlet G, Shields N. The diabetic foot. In: Richardson EG, editor. Orthopaedic

knowledge update: foot and ankle 3. Rosemont (IL): American Academy of Orthopaedic

Surgeons; 2004. p. 125; with permission.


The dorsalis pedis and posterior tibial pulses should be palpated eachtime the diabetic foot is evaluated. Capillary refill, dependent rubor, andpallor should also be noted. Absent pulses are the best predictors of vascularcompromise. Further vascular evaluation includes Doppler studies, payingspecific attention to the presence or absence of triphasic waveforms. An-kle-brachial indices may be obtained, although these are frequently inaccu-rate because of arterial calcification and thus may give false high readings.Beyond these simple tests, further noninvasive evaluation may be pursuedconsisting of arterial Doppler testing, toe pressure measurements, and oxy-gen tensiometry. Finally arteriograms may be necessary prior to reconstruc-tive surgery.

The foot should be checked for dryness, scaling, swelling, thickening ofthe tissues, and the temperature of the foot relative to the lower leg. Cornsor calluses should be examined because ulceration or infection may developin these high-pressure areas, or may be present beneath a callus. It is veryimportant to check the toe web spaces for evidence of tinea pedis, macera-tion, fissures, or ulceration. Global erythema and swelling may representCharcot changes or cellulitis.

Neurologic status is assessed via a history of recent onset of pain, numb-ness, tingling, or other paresthesias. General assessment includes subjectivesensory tests, with comparison to the contralateral limb and more proxi-mally on the leg. Loss of the Achilles deep tendon reflex can also indicateneuropathy. More specific screening tests include the Semmes-Weinstein fil-ament and vibratory testing.

The Semmes-Weinstein filament 5.07 (10 grams) is very useful to deter-mine the degree of protective sensation present in the foot. Many attemptshave been made to standardize the test to determine what areas are best totest [10,11]; however, none of these studies has shown any conclusivedifferences in determining the sensory status of the foot. The disposableSemmes-Weinstein filament is an inexpensive instrument that can be easilymaintained in the office setting. First place the filament on the patient’shand, so he has an idea of the device’s normal sensation. With the patient’seyes closed, touch the bottom of the foot on the plantar surface of three orfour toes and on the plantar surface of the ball of the foot. Depress the fil-ament until it bends, and hold it against the skin for 1 second. Ask the pa-tient to respond to each touch and verbalize the sensation. It is often helpfulto have a family member observe, if only to emphasize the depth of neurop-athy that can exist without the patient being aware of it. If the patient can-not clearly define each touch, it is then reasonable to assume that peripheralneuropathy is present, and that he is losing or has lost protective sensationon the plantar surface of the foot. If there is no positive response to the test-ing, it can be safely assumed that the patient has lost all protective sensation,even if he denies an insensate foot.

A 128-hz tuning fork may also be used to assess neuropathy [12]. Afterapplication of the tuning fork to the dorsum of the hallux interphalangeal

878 FARBER & FARBER

joint, the patient is asked to report his sensation. Another simple tool to de-tect sensory neuropathy is to place the vibrating tuning fork on the dorsumof the hallux, with the examiner’s finger on the plantar surface of the toe. Apatient who is unable to perceive vibration that is sensed by the examinerhas significant neuropathy. If there is a question as to the status of the pe-ripheral neuropathy, then electromyograph (EMG) studies can be obtainedto confirm the diagnosis. These studies, however, are often abnormal in di-abetics regardless of foot status, and they do not quantify the loss of protec-tive sensation.

Special mention should be made of Charcot’s arthropathy. This processwas first described by Jean-Martin Charcot (1825–1893) in referring to neu-roarthropathy in end-stage syphilis patients. Its relevance to diabetic neu-ropathy was subsequently noted, and Charcot’s arthropathy is nowthought to affect up to 7.5% of diabetics [6]. The patient who has Charcot’sarthropathy may develop a deformed, mechanically unstable foot that isprone to ulceration (Fig. 1A–C). The etiology of the Charcot’s process is un-known, but may be triggered by a pathologic vascular response followinga traumatic insult, such as a fall. Increased perfusion to the injured extrem-ity may lead to bone resorption, which in association with sensory and au-tonomic neuropathy increases one’s risk of developing a mechanical

Fig. 1. (A) Charcot’s arthropathy may present initially with a minimally painful foot with intact

pulses and exuberant erythema. If the patient has no fever and no draining ulcer from the foot,

one should consider the diagnosis of Charcot’s arthropathy. (B) Charcot’s arthropathy may re-

sult in joint destruction in the foot and ankle, causing a ‘‘rocker bottom’’ deformity. (C) Pa-

tients who bear weight on a mechanically unstable foot are likely to develop ulcerations

leading to deep wound infections and possible amputations.


deformity. Insensate patients who bear weight on a deformed foot may beunaware that foot ulcerations are forming. Any ulcerations or foot defor-mities associated with loss of sensation in a patient who has diabetes in-creases the risk of eventual amputation 32 fold [13].

Eichenholtz [14] described three stages of Charcot’s arthropathy, anda stage 0 has been added to represent the early clinical setting of a swollen,hyperemic, erythematous foot. Stage I consists of the fragmentation stage,in which fractures and joint subluxation are noted. Stage II is referred toas the coalescence period, when bony fragments are resorbed and the softtissues begin to return to normal. Stage III, or consolidation, describes sta-bilization of the foot by either bony or fibrous union of the involved bonesand joints.

The active Charcot process should be recognized early and not mistakenfor cellulitis, so that supportive and appropriate surgical care can be quicklyinstituted. The usual clinical presentation is the rapid onset of swelling anderythema with varying degrees of pain. The early physical examination mayindicate intact pulses, warm skin, and exuberant erythema. Initial radio-graphs may appear to be normal and the differential diagnosis of infectionversus Charcot change is a difficult one. In the absence of any open wound,chills, or fever, a diagnosis of a Charcot foot or ankle must be considered.Diagnostically, elevation of the leg for a period of 24 hours will result in sig-nificant improvement in the swelling and erythema in an acute Charcotjoint. Even the radiographic changes may present a dilemma as to whetheror not the patient has a Charcot foot or osteomyelitis. In that situation, con-sultation with a foot and ankle orthopedic surgeon and an infectious diseasespecialist should be sought. Fractures noted during this time require that thetreating physician follow the patient closely, and not allow weight bearinguntil solid union of the bone injury has been established and the Charcotprocess has resolved. This is often noted by resolution of erythema andedema in the leg. Prolonged bracing following fracture treatment may benecessary, and this is made difficult by the fact that patients are often non-compliant because they experience no pain and, thus, bear weight on a jointthat is mechanically unstable. In the Charcot foot there is progressive de-struction of the joints of the foot and loss of the normal architecture. Theresulting ‘‘rocker bottom’’ deformity further compromises the mechanicalstability of the foot and ankle. The initial treatment of Charcot arthropathyinvolves bracing and off-loading until the deformity has consolidated. Sur-gical intervention by the foot and ankle orthopedist may be necessary duringor after that period of time to attempt to obtain a stable, shoeable foot.

Prevention

The most important element of prevention is the patient taking responsi-bility for proper care of his diabetic feet. Because the patient is the first lineof defense, education plays a crucial role in the prevention of diabetic foot

880 FARBER & FARBER

problems. Patients must first understand the seriousness of the disease. Sec-ond, they must be educated that their first priority should be good control oftheir overall diabetic condition. Last, patients must learn the basics of goodfoot care and appropriate footwear.

Many resources exist to help educate patients. Many medical societiesand private businesses provide brochures and tear-off pages that can begiven to the diabetic patient to aid in their education and management oftheir foot problems. Local hospitals often run informative programs for pa-tients suffering from diabetes. Teaching patients about foot inspection, at-tention to hygiene, and use of proper shoes, inserts, and appropriatestockings can prevent injury to the at-risk diabetic foot.

General preventative measures that should be strongly recommended in-clude cessation of smoking, appropriate diet, and exercise to help with over-all health. There are also many items specific to the diabetic foot. Avoidanceof extreme temperatures will prevent inadvertent injury that can occur fromtesting hot bath water with the foot, usage of hot water bottles or heatingpads to the insensate foot, and from soaking feet in hot water. Hot surfacessuch as sandy beaches or on the cement areas around swimming poolsshould be also avoided. Chemical agents should not be used to remove cornsor calluses because significant damage can occur to the insensate foot. Shoesshould be checked before being put on to make sure there are no foreign ob-jects that would not be felt but could cause damage. Sandals with a thongbetween the toes should not be used because irritation and skin breakdowncan occur quite readily. The patient should inspect their feet daily, includingtoe web spaces, and should be taught the use of a mirror to observe the plan-tar aspect of the foot and heel to check for worrisome changes. Hygiene isimperative; daily washing of the feet, especially between the toes, can pre-vent serious problems. The patient should use a heavy foot cream that issomewhat thicker than the usual hand lotions. These are available eitherat cosmetic centers, from physicians’ offices, or from shoe stores that special-ize in diabetic care.

Nail trimming is important in order to prevent ingrown toenails and ul-ceration of adjacent toes by enlarged and deformed toenails. Because the di-abetic patient is prone to infection, trimming of thickened or diseased nailsshould be undertaken by the foot and ankle orthopedic specialist, a podia-trist, or a primary care physician familiar with the process.

The vast majority of diabetics, because of the general vulnerability, willdevelop fungal involvement of the toenails. Successful treatment is extremelydifficult. When used properly, topical medications have a poor likelihood ofsuccessfully resolving fungal nail infections. Even treatment with nail drillingor avulsion combined with topical treatment yields success rates of around50% [15,16]. A recent trial of Ciclopirex 8% was more encouraging, buta truly effective topical agent has yet to be proven [17]. Systemic medicationssuch as terbinafine, itraconazole, and griseofulvin can be considered. Thesedrugs are expensive and require periodic liver function monitoring.


Terbinafine appears to be the most effective of these drugs in several studieswith cure rates around 70% [18–20]. However, patients must take terbinafinefor a minimum of 3 months, although a treatment period of 6 to 9 months isoften necessary before improvement is noted. Unfortunately, recurrence ofonchomycosis following systemic treatment is high [18,21]. Occasionally,nail removal may be necessary, and should be undertaken by the foot andankle orthopedist or podiatrist.

Proper shoes and inserts are important in order to prevent pressure areasand subsequent breakdown of the foot. Patients should understand thattheir feet will change over time, and that shoe-wear issues should be revisitedannually. At least two pair of shoes should be available to patients in orderto alternate wearings. Socks of natural fibers that are specifically designedfor the diabetic foot should be used in order to wick moisture away fromthe foot and to prevent pressure from seams. The patient should utilize di-abetic inserts made of specialized materials that accommodate deformityand distribute pressure evenly on the plantar surface of the foot. When de-formities such as bunions, hammertoes, or midfoot prominences exist, ap-propriate treatment may require an extra depth or even a custom shoe toprevent skin breakdown. Medicare currently allows the purchase of onepair of corrective shoes and two pairs of custom-molded diabetic insertsper year for the diabetic patient who is insensate. Coverage may not be ascomplete with other insurance plans, but it is hoped that the diabetic patientwill recognize the need for appropriate shoes, even if they do involve someout-of-pocket expense. Ideally, the diabetic patient should never walk bare-foot, but if any neuropathy is present, unprotected walking should certainlybe avoided at all costs.

Management

Despite the best of prevention programs, diabetics will continue to expe-rience foot ulcers and other problems. To treat high-risk patients, a diabeticteam can be invaluable. This team may consist of the primary care physi-cian, a certified diabetes educator (CDE), an endocrinologist, an orthopedicfoot and ankle specialist, a vascular surgeon, an infectious disease specialist,a podiatrist, a pedorthist (medical footwear specialist), a physical therapist,a social worker, and a home health care service.

Much of the initial responsibility lies in the hands of the primary carephysician. Recognition of the disease state as well as assisting the patientwith adequate control of the blood sugar will slow or prevent progressionof vascular and neuropathic changes in the diabetic foot. An endocrinologistmay offer suggestions on minimizing wide glycemic variability, which, espe-cially in the postprandial state, is known to trigger oxidative stress and in-crease one’s risk for long-term diabetes-related complications [13].

Ideally, treatment would begin with reversal or arrest of neuropathy. Un-fortunately, there is no known cure for peripheral neuropathy as of the

882 FARBER & FARBER

present time. Good control of the diabetes is mandatory to delay the onsetand progression of the neuropathy. In the early stages, if the neuropathy issufficiently symptomatic, drug therapy can be considered to manage thepain. Amitriptyline, gabapentin, carbamazepine, duloxetine, and pregabalinare presently used for this purpose. Only duloxetine and pregabalin are USFood and Drug Administration (FDA)-approved for the treatment of dia-betic peripheral neuropathic pain. No current agents are able to restorelost sensation. Some controversy currently exists about the treatment of di-abetic neuropathy by surgical nerve releases. Several studies have shownpromise for the treatment [22,23], but it is not currently the standard of care.

Once an ulcer or other lesion is identified, implementation of aggressivecare is paramount. The primary care physician can often easily treat smallareas of ulceration. The University of Texas classification [24,25] can helpdetermine when and how to treat ulcers (Table 2). Grade 0 (preulceration)is managed with prevention as discussed earlier. Grade 1 ulcerations maybe managed with pressure relief by special footwear, bracing, or total con-tact casting, and are often within the scope of the primary care physician.Grade 2 ulcerations and Grade 3 lesions need referral to a specialist for ex-tensive surgical treatment, including debridement and possible amputation.The foot and ankle orthopedic surgeon or podiatrist should become in-volved, or the patient should be referred to a wound care center with the ap-propriate resources to treat these complicated patients. Other reasons fororthopedic referral include problematic deformities such as hammertoes,severe bunions, or an Achilles contracture that can predispose patients toabnormal plantar pressures and recurrent ulceration.

There are several key principles to diabetic ulcer treatment at Stage I thathelp to ensure a satisfactory outcome. First, the area of involvement must beoff-loaded, relieving the damaged tissue from weight bearing or pressure.For most diabetic patients, especially if they are overweight, maintainingnon–weight-bearing status is problematic at best. Many techniques existto offload the diabetic foot. Diabetic healing sandals are available in multi-ple forms to offload either the forefoot or heel, and often incorporate

Table 2

University of Texas classification for diabetic wounds

Grade Description Infection

0 Foot at risk None

1 Superficial ulceration None

2 Ulcer penetrating to tendon or capsule þ/� Superficial infection

3 Ulcer penetrating to bone or joint Deep infection

Ischemia grade: A, no ischemia; B, ischemia without gangrene; C, partial gangrene; D, com-

plete gangrene.

Data from Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds.

J Foot Ankle Surg 1996;35(6):528–31; and Brodsky JW. Outpatient diagnosis and care of the

diabetic foot. Instr Course Lect 1993;42:121.


a rocker-bottom sole, as well as accommodative, pressure-relieving inserts.Initial treatment is often more effective with a total contact cast or diabeticleg brace. Total contact casting is a labor-intensive and technically demand-ing process. Outside of a specialized wound care center or diabetic clinic, di-abetic walking boots can be an excellent option. Several investigators haveshown good results using these devices [26,27]. Other advantages include theability to frequently inspect and dress the wound, and ease of application.Diabetic walking boots often have removable inserts, allowing specific areasof the foot-bed to be off-loaded. One study found that using a diabeticbrace, but insuring compliance by using a fiberglass cast wrap to prevent re-moval by the patient, had a success rate equal to total contact casting [28].

Second, local wound care can be accomplished with treatments rangingfrom moist saline dressing changes to expensive recombinant therapies.The choice of dressing is variable, but the goals include maintaining a moistwound bed, absorbing exudates, and creating a barrier against contami-nants. Appropriate sharp debridement is crucial to the success of localwound care. Enzymatic agents alone are often ineffective, and can causegreater harm to local tissues [29]. All necrotic tissue must be removedfrom the wound bed, and surrounding callus needs to be pared down to al-low epithelialization of the wound. Debridement may need to be continuedon a weekly or biweekly basis until the ulceration heels or reaches a stagewhere skin coverage can be obtained by grafting or other procedures.

Third, antibiotic treatment may be helpful when local cellulitis or puru-lence is noted. These wounds are usually polymicrobial, with aerobic andanaerobic gram-positive and gram-negative bacteria involved. Superficialcultures often lead to a confusing clinical picture because of this polymicro-bial involvement. Therefore, obtaining deep tissue cultures of an adequatelydebrided wound leads to better characterization of the offending organisms.Culture-directed antibiotics can then be chosen. In the early stages, oral an-tibiotics are often sufficient; however, when involvement is more complex,parenteral antibiotics under the guidance of an infectious disease specialistmay be necessary. If vascular inflow to the foot is inadequate, then antibiotictreatment is unlikely to be successful. In this setting, vascular interventionsmay be necessary to create a suitable environment for healing.

Summary

Diabetic foot problems are significant causes of morbidity in individualsand impose a high financial cost on society. With good medical care, theprogression of neuropathy and vascular disease can be slowed but notstopped. Therefore, screening and prevention of diabetic foot problems isof paramount importance to decrease the risk of complications and poten-tial amputation. The two most important people in this strategy are the di-abetic patient and the primary care physician. Screening, patient education,disease management, and appropriate referral are within the purview of the

884 FARBER & FARBER

primary care doctor. Screening is comprised of assessment of patient behav-iors, and skin, neurologic, and vascular examinations. Prevention is accom-plished primarily by patient education as well as prescribing neededfootwear or bracing. Initial ulceration management includes off-loading ofhigh pressure areas, ulcer debridement, and local wound care, with or with-out antibiotic treatment. Recognition of Charcot’s arthropathy can greatlyreduce the risk of later problems in affected patients. If ulceration or otherproblems progress beyond the scope of basic treatment, then appropriateand timely referral to other members of the diabetic team is indicated.The team approach, involving the patient, primary care physician, endocri-nologist, orthopedic foot and ankle specialist, podiatrist, vascular surgeon,infectious disease specialist, plastic surgeon, pedorthist, social worker, andnurse educator is the most effective means of controlling diabetic footproblems.

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office-based screening, prevention, and management of diabetic foot disorders

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