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One of the most frightening risks that patients with diabetes face is amputation.
The risk of losing a foot or leg is 15–40 times higher in people living with diabetes than in those without the disease, according to the American Diabetes Association (ADA). More than 80,000 diabetes-related lower-limb amputations are performed every year in the U.S., the International Diabetes Federation reports.
The numbers are indeed troubling. The good news, say experts, is that these amputations are largely preventable. And primary care physicians can play a key role by taking simple steps to more effectively assess their patients with diabetes during routine office visits.
Most physicians already possess the necessary training and skills to perform a simple evaluation and identify potential problems, says Peter Sheehan, MD, director of the Diabetes Center of Greater New York at Cabrini Medical Center and a senior faculty member at Mt. Sinai School of Medicine in New York.
"We really can to do a lot better in this area," he says. "The problem is we haven't yet adequately trained physicians on what they need to be looking for so that we can intervene in a timely way to prevent problems from snowballing." To be effective at preventing amputations, notes Sheehan, providers must implement preventive steps on a regular, consistent basis.
The tools are there, Sheehan says. In fact, one recent study found that, when a screening and treatment protocol for diabetic foot problems was instituted in one managed care organization, the rate of diabetic amputations declined by 47% per year and foot-related hospitalizations dropped 38%.1
OFF WITH THE SOCKS AND SHOES
Perhaps the most important step physicians can add to routine visits with diabetic patients is a thorough foot examination. That means asking patients to remove their socks and shoes at every visit.
"This would do more to reduce amputations than anything else primary care doctors could do," says Andrew Boulton, MD, professor of medicine at the University of Manchester in the U.K. and chairperson of ADA's Foot Council.
Several surveys, however, suggest that most doctors do not routinely inspect their diabetic patients' feet.2,3 Unfortunately, 10–15% of diabetic patients eventually develop dangerous ulcerations—many due to foot problems that are discovered and treated too late.4,5
The foot examination is crucial, Sheehan affirms, because it allows clinicians to detect two of the most important complications leading to amputation—neuropathy and foot problems that can ultimately lead to ulcers and infections.
To do a thorough examination, clinicians should scrutinize all foot and toe surfaces for any problems— from small calluses and hangnails to blisters, scrapes, skin tears, and injuries. Foot deformities, such as hammer toes and high arches, as well as gait problems, such as a drop foot or "pigeon toes," are also important to identify, since these can increase pressure points on the feet, which can lead to ulceration.
"The vast majority of ulcerations occur on the weight-bearing surfaces of the foot, and they're almost always related to pressure," says John Giurini, DPM, chief of the division of podiatry at Joslin-Beth Israel Deaconess Foot Center and associate professor of surgery at Harvard Medical School in Boston. "The most important first step if you see any signs of blistering is to make sure that the patient stays off the foot."
Fitting a proper foot examination into a routine patient visit may seem time-consuming, but a thorough assessment can be completed in less than 2 minutes if all testing implements are laid out and the patient is asked to remove footwear before the clinician enters the room, says Giurini.
"While I can appreciate the dilemma of having little time per patient, I think the downside of this issue is too great to ignore," says Giurini. Virtually any sign of a foot problem—even a seemingly minor one—warrants an immediate referral to a qualified podiatrist, he adds.
"Primary care physicians tend to hold onto patients a little longer than they should. They may identify a problem and start to treat it, but not perceive the severity of the problem or how quickly a small problem can become a serious one in a diabetic patient," he says. "Getting patients to a specialist early in the process rather than later would go a long way in helping us reduce the amputation rate."
SIZING UP SENSATION
Foot ulcers—a common precursor to amputations—rarely have a single underlying cause. One of the most important factors clinicians must be on the lookout for is neuropathy.
The vast majority of diabetic patients who require a lower-limb amputation have sensory loss in their foot and leg. And while most diabetic patients eventually develop this problem to some degree,6 many have no noticeable symptoms or don't realize that the foot pain or numbness they're experiencing is related to their disease.7
Researchers have long recognized a connection between neuropathy and foot ulcers. But in the last decade, prospective studies confirmed that neuropathy can be a direct cause of foot ulcers.8
"It makes sense," Giurini says. "We really need to impress on patients and family members that sensory loss in the feet is common in patients with diabetes, so they have to substitute another sense in order to properly evaluate their feet on a regular basis."
Some common signs of neuropathy are dry, cracked skin as well as feet that are warm to the touch with distended dorsal veins. Another way for physicians to diagnose neuropathy is to perform a simple nylon monofilament test on an annual basis. This quick, highly accurate test involves pressing a 10-g monofilament against various points on the foot sole until the filament just begins to bend. When a patient cannot feel it at any point, it indicates a loss of protective sensation (see "FYI").
Again, referral to a foot specialist is important for any degree of neuropathy, Giurini says. Going forward, physicians must be on particularly high alert with these patients.
"We know now that it's not just neuropathy alone that leads to most ulcerations and infections," he says. "It's a combination of this and some other risk factor like a gait problem, foot injury, or vascular disease."
HOMING IN ON PAD
Another serious but often elusive complication in diabetic patients is peripheral artery disease (PAD). While diabetes is the most powerful risk factor for PAD, many diabetic patients who develop the disease don't present until they've developed limb-threatening tissue ischemia.9
"Part of the problem here is that most diabetic patients don't have the classic PAD symptom of claudication," Sheehan says. "The symptoms are usually much more subtle."
These can include heaviness, general fatigue, slow walking speed, and lack of palpable pulses in the foot even if the skin is warm and pink, he says.
In addition, ADA now recommends routinely screening for PAD in patients with diabetes using the ankle brachial index (ABI) in all patients >50 years and in younger patients who have had diabetes >10 years, as well as in patients with other risk factors such as smoking, hypertension, or hyperlipidemia.10 This simple test requires a blood pressure cuff and a handheld Doppler probe (DOC News, November 2006, page 14) (see "FYI").
"The ABI measurement is enormously productive, especially in terms of identifying PAD in asymptomatic patients," Sheehan says. "Not only could it be limb-saving, it could also help us reduce the enormous cardiovascular and cerebrovascular risks these patients face."
Any signs of PAD warrant a referral to a vascular specialist, Sheehan adds. And contrary to what some physicians believe, patients with diabetes are excellent candidates for revascularization therapies as needed.
With proper screening and the multidisciplinary care a good team of health
care professionals can provide today, amputations may start to drop
significantly, Sheehan says. "The no-option patient is rapidly
disappearing." 
Advocates Call for Better Coverage of Prosthetics for Amputees
Many health insurers have drastically capped or even eliminated coverage for diabetic and other patients who require prostheses following an amputation.
That can be shocking news for many amputees, considering the average cost of a prosthetic limb is $10,000–$15,000.
Fortunately, the tide is beginning to turn. Thanks to the efforts of the Amputee Coalition of America (ACA) and other advocacy groups, six states have recently enacted laws mandating full prosthetic coverage for their residents. Colorado was the first to pass a so-called "prosthetic parity law," followed by Maine, New Hampshire, Rhode Island, Massachusetts, and California. Pennsylvania also is expected to pass a similar version of the state legislation this year. And efforts to introduce prosthetic parity legislation are moving forward in several other states. Some of the new legislation requires full coverage for doctor-prescribed orthotics and prosthetics, as well as appropriate repairs and replacements, with no co-pays or caps. Other bills require insurers to match the federal Medicare coverages for these devices.
"The ACA is working hard to make sure patients get the coverage they need," says Paddy Rossbach, RN, president and CEO of the coalition. "We need the support of practitioners and industry partners to continue to build and enhance our efforts."
For more information, visit the ACA Web site at www.amputee-coalition.org.
Footnotes
For more information on foot problems and wound treatment for diabetic foot ulcers, refer to the Clinical Practice Guideline published by the American College of Foot and Ankle Surgeons. Frykberg RG, Armstrong DG, Giurini J: Diabetic foot disorders: A clinical practice guideline. J Foot Ankle Surg 39 (Suppl. 1):S1–S60, 2000.
Clinicians can obtain a monofilament kit and literature on diabetic foot management (item #NDEP-2) at a small cost from the National Diabetes Information Clearinghouse, 301-654-3327.
For guidance on measuring ankle brachial index, refer to the ADA consensus statement. American Diabetes Association: Peripheral arterial disease in people with diabetes (Consensus Statement). Diabetes Care 26: 3333–3341, 2003.
More background and clinical practice information is also available from the PAD Coalition at www.PADCoalition.org.
References
2. Wylie-Rosett J, Walker EA, Shamoon H, et al.: Assessment of
documented foot examinations for patients with diabetes in inner-city primary
care clinics. Arch Fam Med 4:46–50, 1995.
3. O'Brien KE, Chandramohan V, Nelson DA, et al.: Effect of a physician-directed educational campaign on performance of proper diabetic foot exams in an outpatient setting. J Gen Intern Med 18: 258–265, 2003.[Medline]
4. Singh N, Armstrong DG, Lipsky BA: Preventing foot ulcers in
patients with diabetes. JAMA 293: 217–228, 2005.
5. Reiber GE, Ledoux WR: Epidemiology of diabetic foot ulcers and amputations: Evidence for prevention. In The Evidence Base for Diabetes Care. William R, Herman W, Kinmonth AL, et al., Eds. Chichester, U.K., John Wiley & Sons, 2002, pp.641 –665.
6. Harati Y: Diabetic peripheral neuropathy. In Medical and Surgical Management of the Diabetic Foot. Kominsky S, Ed. St. Louis, Mosby-Year Book, 1994, pp.73 –85.
7. American Diabetes Association nationwide telephone survey results: What you don't know about diabetic neuropathy can hurt you. Published online at www.diabetes.org/for-media/2005-press-releases/diabeticneuropathy.jsp May 10, 2005. Accessed December 11, 2006.
8. Boulton AJ: The diabetic foot: From art to science: The 18th Camillo Golgi lecture. Diabetologia 47: 1343–1353, 2004.[Medline]
9. Sheehan P: Peripheral arterial disease in people with diabetes:
Consensus statement recommends screening (Commentary). Clin
Diabetes 22:179–180, 2004.
10. American Diabetes Association: Standards of medical care in
diabetes—2006 (Position Statement). Diabetes
Care 29 (Suppl. 1):S4
–S42, 2006.
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