Presentation And Diagnosis

The diabetic foot enters stage 2 when it has developed one or more of the following risk factors for ulceration: neuropathy, ischaemia, deformity, swelling and callus.

These risk factors may not cause symptoms. Patients do not, thus, report problems. It is therefore important to screen patients at the annual review, which is an important part of diabetic foot care. A recent evaluation of a diabetic foot screening programme showed that it could prevent major amputations. A large randomized controlled trial of 2001 diabetic patients compared outcomes in 1001 patients who were screened for risk factors and 1000 in the control group who were not screened. The people at risk of foot ulceration in the screened group were treated with podiatry and education. At the end of 2 years there was only one major amputation in the screened group compared with 12 in the control group, which is a significant difference.

Neuropathy and ischaemia are the two most important risk factors for the diabetic foot. Deformity, swelling and callus do not commonly lead to ulceration in patients with intact protective pain sensation and a good blood supply, but when they are found in combination with neuropathy or ischaemia they significantly increase the risk of ulceration. There are other factors which increase risk, including diabetic complications, medical conditions and social problems:

• Social isolation—'lack of social connectedness'

• Intellectual deficit

• Concurrent psychiatric illness

Every diabetic foot at stage 2 will be classified as neuropathic or neuroischaemic. It is necessary to emphasize the great divide between the neuropathic foot, which lacks protective pain sensation but has a good blood supply, and the neuroischaemic foot with a combination of neuropathy and ischaemia, because the treatment will be different in the two groups.

This chapter considers (under 'Vascular control') two non-ulcerative complications of the neuroischaemic foot:

• Severe chronic ischaemia

• Acute ischaemia.

It also discusses three specific but non-ulcerative complications of the neuropathic foot:

• Painful neuropathy

• Neuropathic fractures

• Charcot's osteoarthropathy.

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