1. Chapter VIII
MINIMUM CARE PROTOCOL
FOR DIABETIC FOOT
THE PROCESS OF DEVELOPMENT
DEVELOPMENT OF PROTOCOL FOR
o Examination of diabetic foot
o Assessment of ulcers
o Laboratory assessment
o Treatment and
o Prevention
NNEF and a number of recognized experts in diabetes foot care in India have
worked closely since December 1999. A consistent effort through well structured
Diabetic Foot Care workshops has been made to bring about professional awareness
in India, with the help of the experts, coordinated and supported by NNEF till date.
A major offshoot of these efforts was the formation of National Foot Group in
Chennai in December 1999 which later evolved formally as Diabetic Foot Society of
India.
A meeting of National Foot Group was held in Bangalore on July 22nd, 2001 for
review the developments brought about by the NNEF - Experts combine and to
make an attempt to develop a consensus on “Minimum Care Protocol for Diabetic
Foot.” 40 members of the National Foot Group attended the meeting. This
document is the outcome of the recommendations for these members of National
Foot Group.
The Process of Development of the Protocol:
TThe assembled members were explained the idea of Minimum Care Protocol For
Diabetic Foot by Dr. Ashok Kumar Das, Convener and Chairman of the National
Foot Group. Dr. Das emphasized the need for a uniform minimum standard the
professionals who take care of diabetic foot should follow. This endeavor also allows
for the outcome analysis of treatment and could throw light on the areas that need
greater concentration, Dr. Das explained. According to specific area for
consideration the group was divided as shown below with the leader.
1. Prevention Group - Dr. A K Das
2. Foot Examination - Dr. Sharad Pendsey
3. Foot Ulcer Assessment - Dr. Arun Bal
4. Laboratory Assessment - Dr. Vijay Vishwanathan
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2. 5. Treatment - Dr. K R Suresh
Each group agreed upon the minimum care protocol required to be followed in their
area for consideration. The recommendations were recorded on OHP sheets,
presented by a group member, were discussed by all and then accepted with
suggestions at few places.
Minimum Care Protocol For Diabetic Foot
Group 1
Prevention of Diabetic Foot Development and / or complications
The group emphasized the lack of standards in diabetes foot care and felt that this
document should be practical, as widely applicable as possible and should be
affordable to all concerned.
In order to prevent the development of diabetic foot and / or its complications we
need to -
•• Highlight the diabetes foot problem in practice.
•• Highlight the same in the context of diabetes disorder.
•• Emphasis on the Indian socio-economic conditions that may lead to diabetic foot,
further complicated by customs beliefs and practices among Indians.
•• Emphasis on examination for neuropathy since that forms the bulk of the problem.
•• Address equally the city and village population with diabetes also, as the latter are
highly vulnerable to injury and ulceration .
•• Emphasis on not “walking bare foot”.
•• Self examination of foot taught to persons with diabetes.
•• Reporting symptoms early to prevent serious complications patient education
necessary.
•• Avoiding Tobacco particularly among persons with diabetes.
•• Examination of footwear.
•• Control of hypertension, diabetes, lipids.
•• Investigations to identify foot at risk.
•• Monofilament testing.
•• Doppler for AB index.
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3. •• Other vascular studies if available.
•• Audio visual aids to explain the patients risks.
•• Advising on as ideal a foot wear as possible.
Educational materials:
•• Easy to read, pictorial and in regional languages.
•• Step by Step approach to foot care educations should be reached to all involved in
diabetes and foot care in particular.
•• Revised as necessary.
•• Documentation of work there from draw lessons in own practice.
Standard Formats to document care:
•• Measuring outcomes.
•• Publication/complication in Indian context to be used as a guide for all.
SLOGAN: “Save Diabetes Foot Reduce Economic Burdens”.
Group 2
EXAMINATION OF FOOT:
History:
Parasthesias Claudication
H/o Diabetes Mellitus Injury by Thermal Exposure
Massage Shoe bite
Past h/o ulcer
Examination:
Inspection
•• Skin texture
•• Colour - Pale, Red, Blue, Black
•• Loss of Sweating
Palpation
•• Warmth, Tenderness
•• Calluses, Fissures, Bony prominences
•• Deformity, Web spaces, Nails
•• Joint movement
Foot Pulses
•• Dorsalis Pedis, Posterior Tibial, Prominent veins
•• Vascular Examination and Risk Assessment:
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4. •• A/B Index Doppler
Foot Pressure measurement:
•• Ink Pad, Harris Mat, PodoTrack
•• Footwear inspection for foot impressions.
Risk Assessment:
•• Protective sensation- Pinprick for pain, Cotton wool for touch
•• Temperature, Vibration by Tuning Fork or vibration threshold measuring
instruments, Touch and Pressure Monofilament l Joint sensation limitation Subtalar/
big toe
•• Joint movement limitation Reflexes and Jerks
RISK CATEGORY:
Group 3
FOOT ULCER ASSESSMENT IN DIABETES MELLITUS:
H/o duration, trauma, bare foot or incorrect walking, foot wear, varicose veins,
previous ulcer
H/o occupation, profession
H/o tobacco, alcohol
Examination of the Ulcer:
•• Site, Size, Edge, Shape and Base of the Ulcer
•• Slough, Discharge, Exposure of bone, tendon
•• Surrounding Tissue, Warmth
Examination of the Foot:
•• Deformity
•• Pulsation
•• Edema over foot
Investigation:
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5. •• X ray foot, Bacterial swab
Treatment of specialist when:
•• Ulcer with Discharge Surrounding tissue oedema
•• Cellulitis Lymphangitis
Group 4
AIM TO INDENTIFY THE HIGH RISK FEET
LABORATORY INVESTIGATION:
A Sensation Large Fiber -Tuning Fork, Monofilament
Biothesiometer Optional
Small Fiber-Pain Sterile needle 26 G
Temp test tube, Tip Thermo
B Vascularity Clinical exam-Palpation of peripheral vessels,
A/B index, Duplex, Angiogram (optional)
C Pressure and Mobility Clinical examination Movement- Subtalar/ Big Toe
Harris Mat (Optional) Computer assessment (optional)
D Radiology X ray AP/OBLIQUE, Ultrasound Nuclear Scan --> On
expert advice
E Metabolic Hemogram
Sugar, Glycosylated HBA1c
Renal Parameters, Nutrition S. Albumin
F Microbiology Wound cultures, Blood culture and Antibiotic sensitivity
Lab test On first Once every Once every Once every Acute
examination 12 months 6 months 3 months infection Risk 0
Risk 1 Risk 2 Risk 3
A SENSATION + + + + +
B VASCULATURE + + + + +
C PRESSURE AND + + + + +
MOBILITY
D RADIOLOGY +(If swelling + + + + is present)
E METABOLIC According to + + + + usual guidelines
F MICROBIOLOGY – – – – –
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Group 5
PRIMARY LINE OF TREATMENT
1. Wound assessment, '3D' assessment
Mapping with a plastic sheet as guide
Mapping every 2 weeks
Photographic evidence digital photography
Grading “Depth Ischemia Scale”-Wagner's classification
2. Primary Neuropathic wounds
Marking on chappals
Noting corns and calluses
Therapy-Shaving calluses and modifying footwear
3. Infection:
Warmth, discharge, unhealthy base
No improvement in three days-refer to specialist earlier if patient worsens
Culture and sensitivity
Penicillin and clavulinic acid (Sulbactum)
4. Circulation Palpation of pulses
(Venous filling time, Capillary filling time)
