Neuropathic Foot

Question 1

Why is important to learn about neuropathic foot?

Answer 1

50% with diabetes will develop neuropathy
leading cause of diabetic hospitalization
implicated in 50-75% of non -traumatic amputations
costs as much as $13.7 billion (amputations up to $1 billion)
mortality rates after amputation increase by 40% at one year, 80% at 5

Question 2

What are causes of neuropathy?

Answer 2

Diabetes
tumor, trauma, and other conditions
autoimmune disease (RA, GBS, SLE)
vitamin B, E, or niacin deficiency
exposure to toxins (chemo, heavy metals, etc)
infections (HIV, lyme disease, shingles)

Question 3

What are the 4 types of neuropathy?

Answer 3

peripheral: affects UE or LEs
autonomic: affects cardiopulmonary system, temperature regulation, bowel, bladder, and sexual function
proximal: affects thigh, hip, and core muscles
focal: sudden loss of function in one nerve or a group of nerves

Question 4

When should a foot exam be performed?

Answer 4

comprehensive exam should be completed at least annually; more often if complications exist
those with neuropathy should have feet visualized at EACH medical visit
those with diabetes should check their feet EACH day at home
look for cuts, blisters, s/s of infection, etc
use mirror if needed
enlist help of family/friends

Question 5

What are the goals of foot exam?

Answer 5

establish history/diagnostic factors
identification of risk
intervention
education
EARLY INVOLVEMENT IS CRUCIAL

Question 6

What should you include in the subjective exam?

Answer 6

Contributing diagnosis (DM, HIV, etc)
PMH and social factors
Medications
Complications: neuropathy, nephropathy, retinopathy, vascular disease (central or peripheral)
History of LE surgery, ulcer, or amputation
Current smoker/smoking history
HbA1c (if diabetes): averages blood sugar control over several months, it’s a %

Question 7

What should be included in objective exam?

Answer 7

condition of skin, hair, and toenails
deformities
pulses
sensation
shoe wear

Question 8

How do you evaluate skin?

Answer 8

Look if it’s intact.
is it thin, shiny, brawny, and/or frail
dry
calluses/wounds

Question 9

How do you evaluate hair?

Answer 9

a sign of circulation. look at if it’s present or absent

Question 10

How do you evaluate toenails?

Answer 10

are they thickened, deformed, ingrown

Question 11

What deformities should you look out for?

Answer 11

prominent metatarsal heads
hammer/claw toes
hallux valgus (bunions)
charcot foot

Question 12

What are claw toes?

Answer 12

hyperextension of MTP with PIP and DIP flexion

Question 13

What are hammer toes?

Answer 13

hyperextension of MTP and DIP joints

Question 14

How do you treat hallux valgus?

Answer 14

splint and keller bunionectomy

Question 15

What is charcot arthropathy? treatment?

Answer 15

progressive bone destruction and ligament damage leading to arch collapse and impaired skin integrity.

treated with complete immobilization in a total contact cast, protected weight bearing

Question 16

Who gets charcot arthorpathy? Cause?

Answer 16

affects about 9% of those with diabetes

unclear if etiology is neurotraumatic, neuro-vascular, or both

Question 17

What pulses should you palpate for in your exam?

Answer 17

posterior tibialis, dorsal pedis

Question 18

What is the ankle brachial index (ABI)?

Answer 18

you take BP of UE and BP of LE and divide them

Question 19

What does a ABI measurement of >1.2, 1.2-1.0, 0.99-0.90 mean?

Answer 19

> 1.2= vessels are incompressible, consider toe brachial indexes

1. 2-1.0= Normal
2. 99-0.90= Acceptable

Question 20

What does a ABI measurement of <0.50 mean?

Answer 20

<0.50= severe arterial disease

Question 21

How do you assess sensation?

Answer 21

Semmes Weinstein Monofilament: 10g (5.07) monofilament, normal sensation is 1g so if you can’t feel 10 g you have lost protective sensation, 10 locations on foot (some sources say 12-13)

vibratory sensation: 128 Hz tuning fork, latency of 10 seconds or more indicates sensory loss, normal is 5 seconds

Question 22

How is someone a low risk assessment?

Answer 22

preserved sensation, no deformity, intact circulation: annual foot exam, education, good footwear

Question 23

How is someone a high risk assessment?

Answer 23

sensory loss, deformity, vascular disease, callus formation, history of ulcer, or amputation: comprehensive assessment, education, certification for diabetic shoes (if possible)

Question 24

What is a critical part of taking care of neuropathy?

Answer 24

Documentation! especially if trying to get diabetic shoes

Question 25

As a PT what is the most important part of your intervention?

Answer 25

EDUCATION!!!!
general diabetes self care, foot/skin care, daily skin checks, proper footwear (breathable, adjustable, wide toe box, good support)

Question 26

What are two other parts of you intervention besides education?

Answer 26

Ulcers: dubulk callus (therapist or podiatrist), control moisture (wound and skin), decrease infection risk (silver products and antibiotic), edema management

pressure: offload pressure areas

Question 27

How can you offload the foot?

Answer 27

total contact casts: change every 1-2 weeks
orthotics/walking boot
surgical shoes
dressings: foam or felt
cutouts: reduce pressure points in shoe
assistive devices
elevate heels with pillow under calves

Question 28

What is covered by medicare?

Answer 28

covers 80% of cost of one pair of depth shoes and 3 pair of inserts
covered if following are met: patient has DM and patient has one or more of the following (poor circulation, foot deformity, history of partial or complete amputation, history of previous foot ulceration, history of pre-ulcerative callus, peripheral neuropathy with evidence of callus formation

Question 29

How do you educate patients on foot care?

Answer 29

check feet daily
always wear shoes
do not apply lotion/oil between toes
have nails clipped by health care professional
manage calluses with emergy board/ped-egg
vicks vapor rub or tea tree oil for onychomycosis
immediately report changes

Question 30

What are 4 other possible areas of patient education?

Answer 30

Exercise: >30 min/day, ideally both aerobic and resistance; consider foot integrity

Nutrition: monitor BMI, encourage (stable) weight loss; fresh fruits and vegetable (frozen better than canned); glucose levels before meal 90-130 mg/dl; glucose levels after meals less than 180 mg/dl

glycemic control: HbA1c goal of <6.5-7

specialist referrals: podiatry, wound care, nurse, educator, dietician