Top Tips in 2 minutes

What can you tell of a man by the shoes he steps out in? If possessed with the analytic prowess of Sherlock Holmes then ‘a little reddish mould adhering to your instep’ might be all it takes to tell that your long-suffering companion Watson has been to the Post Office on Wigmore Street where ‘they have taken up the pavement and thrown up some earth, which lies in such a way that it is difficult to avoid treading in it on entering.’¹

As affected as such comments may now sound to our modern ear, there is much to commend the detective's ability to put together a story from careful observation of footwear.

Sometimes the story shouts out loud. The shoes in the picture below belonged to an eccentric but socially-isolated man with neuroischaemic feet who tried to accommodate the swelling from the infected ulceration of his left second and right first toe by de-lacing his shoes and adding bespoke vents with tin snips from the shed.

More often the story is more subtle, made more difficult by the injury amnesia engendered by neuropathy. However, diabetic foot lesions are not miraculous stigmata. There is always a reason to explain their appearance and the answer is often lying at your feet. If visual inspection draws a blank, run your hand carefully along the inside of the shoe worn when the injury occurred. Lost pins, coins, front door keys, and golf balls (honest!) will all be rediscovered. As Holmes explained to Watson, ‘Eliminate all that is impossible, whatever remains is the explanation, however improbable.’

Top Tips in 2 minutes: Diabetic feet.

Why:	Patients with diabetes-related foot disease have some of the longest in-patient stays; the associated comorbidities place these individuals at high risk of premature death. Many of the lesions and associated hospitalisation/amputation are avoidable with good self care, early effective management, and early referral when needed. Late referral results in early amputation.
How:	Many problems present without pain as a result of peripheral neuropathy. The absence of pain should NOT be taken as reassurance that there is not a serious problem. If problems are treated early enough, amputation can often be avoided, function can be maintained and length of stay decreased. Patients should have regular foot checks – annually for all and more frequently if neuropathy, peripheral vascular disease, or foot deformation. Monofilament testing is only part of the assessment and a patient can still have a high-risk foot even with normal perception of a monofilament. If a lesion is found, ask yourself why this lesion in that position on that foot? Lesions do not appear by magic and a simple history, seeing how the patient weight-bears on their foot when standing plus looking at the footwear they were (or were not!) wearing when the lesion developed can be hugely informative. A foot lesion can be the presenting feature of previously unrecognised diabetes. Always, always look at the other foot. The same risk factors (neuropathy, peripheral vascular disease, callus, poor nail care, footwear) are invariably present and often there are second lesions that the patient didn't even know they had.
What next and when:	If a lesion is found, address 5 key areas: Infection – This is a clinical diagnosis and a swab result will never tell you when to start antibiotics. However, swabbing open lesions before commencing antibiotics will help to ensure you've made a sensible choice – who says every bug is sensitive to flucloxacillin? Vascular – Are there pulses? Do not be falsely reassured by your Doppler machine. The inability to detect pulses with your fingertips is an abnormal finding and should be respected as such. Mechanical – Consider how you might reduce weight-bearing on the affected area. Metabolic – Treat hyperglycaemia aggressively. Social – Can the patient undertake their daily activities if they are reducing pressure on the lesion?
	Remember, there is no dressing in the world that will sort out deep infection, vascular insufficiency, or severe abnormal pressure loading. If you don't know how to tackle these issues, ask someone who does.
	Advise all patients: Good footwear is essential – have your shoes fitted. Check and moisturise feet daily (get someone else to do it if you can't). Refer to community podiatrist/foot protection team if neuropathy, absent pulses, callus, deformity, or other risk factor for ulceration.
	Refer to the specialist foot clinic if: Ulceration and no foot pulses. Ulceration and infection/cellulitis. Suspected Charcot's arthropathy of the foot (hot, swollen, red foot). Necrosis/gangrene. Have a much lower threshold for immediate referral for anyone who has previously had an amputation and develops a new lesion.
	Even when the index lesion has healed, always think ‘What can I do to stop it happening again?’ Many of these patients need specialised footwear and some require consideration for surgical intervention.
Patient information:	http://www.patient.co.uk/showdoc/27000145/
References/Web links:	Edmonds M, Foster A. Diabetic Foot ulcers.BMJ 2006; 332: 407–410 http://www.bmj.com/cgi/content/full/332/7538/407http://www.diabetes-healthnet.ac.uk/HandBook/ScreeningOfFoot.aspx
Who are you:	Dr David Simmons (Community Diabetologist); Mrs Lucy Bishop (Senior Podiatrist); Ms Cathy Eaton (Senior Podiatrist); Dr Tony Coll (Hon Consultant Physician). The Diabetes Foot Team, Wolfson Diabetes and Endocrine Clinic, Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge.
Date:	18 April 2008: Review April 2010