Prevention and Early Intervention for Diabetes Foot Problems
3. Causative Factors continued...
Precipitating or Pivotal Events
In the causal pathway study noted above, foot trauma was caused by shoe-related repetitive pressure leading to cutaneous ulceration in 36 percent of all cases, accidental cuts or wounds in 8 percent, thermal trauma (frostbite or burns) in 8 percent, and decubitus ulceration in 8 percent15. Similarly, another study found that in one-third of diabetic amputees with peripheral arterial disease, the initial lesion was self-induced. The most common cause of self-injury was ill-fitting new shoes; the second most common cause was cutting toenails improperly16. Other investigators identified external precipitating factors in 84 percent of study patients with foot ulcers. The most common factors were ill-fitting shoes/socks, acute mechanical trauma, stress ulcer, and paronychia17.
4. Screening for Patients at Risk
Screening Tools to Identify High-Risk Feet
The importance of identifying individuals at risk for foot ulceration and LEA and the need for preventive foot care practices for both the provider and the patient have been noted18. Several simple screening tools have been developed to identify people at high risk. These tools include a patient report and a clinical examination to quantify loss of peripheral sensation, foot deformities, peripheral vascular disease, and prior foot ulcers. Use of these measures has been shown to predict subsequent ulceration and amputation19.
In one study, during annual patient examinations, researchers recorded the presence of a foot deformity, history of lower extremity ulceration or amputation, and the ability to perceive the Semmes-Weinstein 5.07 10-gram monofilament at eight sites on the plantar surface of each foot. Based on the findings, subjects were classified as sensate or insensate and placed in one of four risk categories. Insensitivity to the monofilament occurred in 68 (19 percent) of the patients screened. Over a 32-month follow-up period, 41 of these patients developed ulcerations and 14 amputations occurred19.
Identifying patients' risk category for foot ulceration helps to determine the frequency needed for provider foot examinations, the level of emphasis on self-care of the feet, and patient responsibilities20.