-Good day everyone.
My name is Mike Edmond.
-My name is Neil Baker.
-We're going to talk on foot examination
and the skills you need to develop to perform this properly.
-The key messages of this presentation which we will share with you
are when we are examining a patient to be able
to examine for the presence of sensory neuropathy
loss of protective sensation.
Examining for deformity being able to identify arterial supply
and obviously taking a history to see
if there's any evidence either clinically
or verbally of previous foot ulceration as these
are the most important risk factors for foot ulceration.
Patients are often unaware of the problem
and regular foot screening is required to detect these pathologies
in order to help patients identify their feet at risk
and then for something to act importantly.
It must also be stressed that the whole of this process is one of education
so to ask the patient why we are doing
what we are doing is as important as actually what we are doing.
The risk status classification is based on the presence of
as we've said, the loss of protective sensation.
Identifying foot deformity
and by foot deformity, we mean deformity
that cannot be accommodated in a normal high street shoe.
Feeling for foot pulses, so that's the dorsalis pedis and posterior tibial pulse
and any history of previous foot ulceration, or amputation
and of course after the examination of the foot
each patient can be assigned a risk category
and we will direct you to the previous slides we had on risk stratification
and of course once categorization has been done
patient should be then put into some management program
with regular follow-ups.
Obviously, the objectives are again
of the foot examination are to recognize deformity
callas, being able to look at things like the fibrofatty padding
under the metatarsal heads to see if this is atrophied
thinned wasted away, move distally
how to use a 10-gram monofilament and a tuning fork
because they can be used well and they can also be misused.
Knowing how to check for foot pulses and asking for any history
into medication or risk pain and having a good look at the skin
and the nails to see what the tissue vitality is
and then knowing how to record this information.
We will be doing a video which you can look at which
will help you with these techniques we've just described.
If we look at this pictorial reference here
you can see the use of a 10-gram monofilament at about one o'clock
the use of a tuning fork below this about five o'clock
is the callus, moving around to 6 o'clock and 7 o'clock.
You can see our patient's foot pulses.
The first one is posterior tibial pulse palpation
the second one is the dorsalis pedis
so that's the one on the far left
and then at the top of the screen you can see very clearly somebody
that has an overriding second toe and hallux valgus deformity
which obviously would not be fitted
into a high street shoe therefore this patient has deformity.
-The general approach to the assessment of the diabetic foot is threefold
first, simple inspection, secondly palpation, and third, sensory testing.
Palpation and sensory testing will be demonstrated on the videos.
On a general inspection, it is important to look for evidence of neuropathy
ischemia, deformity, edema and also important to examine the footwear.
These are the features of the classical neuropathic foot
and on the clock face going from one o'clock
we have sensory loss which you could pick up with the filaments
there is a dry skin, second be autonomic neuropathy and also fissures
there is loss of joint movement as part of the neuropathic foot
nail dystrophies, and in this foot
you can see the archers slightly elevated
and there is high pressure point would be under the metatarsal head.
This can lead to ulceration and is often preceded by callas.
The ulceration can be complicated by infection.
Overall, it's important to look for deformity in the neuropathic foot
and these deformities tend to fall into two groups
the forefoot deformities related to the metatarsals and the toes
and of course the charcot deformities related to bone
and joint disruption of charcot arthropathy.
In contrast to the neuropathic foot are the features of the ischemic foot
where there is a reduction in blood supply and poor tissue nutrition.
Again, going from one o'clock
there is the evidence of necrosis of the distal part of the toe
and gangrene pulses will be reduced absent
at the posterior tibial and the dorsalis pedis.
Often when there is a severe degree of ischemia
there is pain present, what we call rest pain affecting the muscles
and the bones of the foot.
Such is the pain that there may well be coexisting depression in the patient.
Deficiency in the nutrition of tissues will lead to soft tissue atrophy
and thin atrophic skin, and thin callas.
The color can be variable
at one stage one has the pink painful foot
where it's deceptively so-called healthy foot being pink
but it's related essentially to the capillary dilatation in response to the ignacia.
In general, the ischemic foot is cool
but occasionally, it can be warm related to the autonomic neuropathy
and one standard method of assessing the foot is the ABPI
but beware of medial calcification
and finally there are the nail dystrophies
which are present and the toes looking like beef sausages
their reddened appearance.
Just to show you the signs of autonomic neuropathy again
the dry skin, absence of sweating
deep fissures, particularly in the heel
and another sign of autonomic neuropathy
the dilated veins related to arteriovenous shunting
lack of sympathetic basic construction of the AV shunts.
Therefore they're opening and leading to a venous dilatation.
One should always look out for deformity
and in the end stage one can see the marked deformities of charcot
here we see a hind-foot abnormalities with disruption
of the ankle joint on the left and on the right showing associated
complicated ulceration and infection.
Always look at the footwear
and as you can see this patient presented with a nail apparent
through the sole of his shoe and this coincided with a plantar ulceration.
The patient was completely unaware of this
and in fact, it gone right through the sole and caused tissue breakdown.
In so doing and looking for these features
one will also specifically look at local lesions
preoperative lesions, skin and nail lesions as we've demonstrated
infection and necrosis and in rare circumstances
if the lesions look atypical always think of malignancy
where squamous cell lesions maybe present
on the plantar surface and should be referred to a dermatologist without delay.
-Now we're going to come on to something slightly different.
Having gained some of this knowledge it's good to share.
Very often you may be called upon to run workshops
on how to examine a foot and test for some of these things.
The next few slides are really just to give you some top tips
on how to run a practical workshop
and the main pitfalls there are in doing one of these.
Important thing before you do any workshop
is to make sure that the room that you're going to use
has adequate space for the delegates to get into groups and examine feet
or if you having patients for them to examine feet
and being able to accommodate the patient's feet
and think about respect and confidentiality.
Always be aware that in any group of people wanting to learn
there will be the shy versus the confident versus the arrogant.
One of your jobs as a trainer should you choose to do this
is knowing how and developing skills
in involving the shyest person in the room
and knowing how to very tactically deal
with some of these overconfident or arrogant
and making sure that everybody is involved in this process
because everybody needs to learn.
Make it fun, if you have fun you will learn far more benefits very serious.
There is a balance between having too much fun and having none
so balance is important.
You will need facilitators to roam around
and observe people as they're examining feet.
Get your facilitators to actually pick up on any problems
that you may see existing and any flaws
that they may be in the use
for example, a 10 gram monofilament
or the way in which somebody is palpating a pulse
because sometimes we think we know how we are doing it
and it's not until we are observed that actually
we find out we've been doing this wrong.
You need to make sure there's enough testing the equipment.
There's nothing worse than sitting in a room waiting
for a 10-gram monofilament to be passed around 20 people
because you'll lose your audience.
You need to decide where you're going
to actually use something like a 10-gram monofilament.
You need to decide what your gold standards are.
I would certainly direct you to the International Working Group guidelines
where you can look at the number of sites
that should be tested and what the cut off values are.
Always remember, it's a good idea to demonstrate on the volunteer first.
Remember too that screening is about education.
Always ask people why am I doing this to your foot?
What does it mean?
What implications does it have to you?
Make sure that candidates take around in the room
and the room that people go to be examined
because people like to stay in nice closed environments
where they get some with each other.
Then you need to be able to explain the common pitfalls
of the screening tests are around.
For example, banging a tuning fork on the floor
and hearing the hummer before it's even touched the patient
they know that it's coming.
That's a very common pitfall.
Always make sure that everyone is engaged and nobody sits out at the edge.
Making sure that people are all involved in this is really important.
You won't learn unless you do.
Then having a method of feedback at the end of each session is really important.
Interaction always is important
because you learn as well as the other people who are being educated.
Ask individuals for their comments.
Don't forget to revisit these screening skills during live patient examinations
particularly those of you who are going to do foot training programs.
Remember that the screening tools and the techniques
will be used on live patient demonstrations
during the training of foot training programs.
Last but not least, listen to the patient.
If you've got a live patient talk to the patient, have empathy with them.
Remember, you need to get their consent if people are going to take photographs.
You need to discuss this with the patient.
It is really important otherwise it is a real invasion of privacy.
That's an important thing you must take away with you.
You need to prepare yourself beforehand
making sure that your hands are clean
and the patient sees that you're actually cleaning your hands.
Take off your jewelry make sure your fingers aren't 15 inches long
with loads of dirt underneath
make sure your hair isn't falling in your face
and make sure that your clothes or your uniforms are very clean.
The key message is really from this slide set
which Mike and I have delivered to you
is make sure that you know how to assess a foot
what to look for, and that once the patient has been examined
has been screened because this is a screening process
they are assigned to a risk category.
The important thing too for that is to make sure
that the patient knows what their risk status is.
It's pointless for you to categorizing them and not telling the patient.
Once you've done that
just make sure that there is an individual follow-up program
and management program for each individual patient.
We would like to thank you both Mike and I for your attention.
Bye.