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| A) | Cataracts | ||
| B) | Osteoarthritis | ||
| C) | Peripheral neuropathy | ||
| D) | Repetitive strain and overuse |
Diabetic foot complications are a major source of morbidity and disability among people with diabetes. Peripheral neuropathy, peripheral arterial disease, foot deformities, and other diabetes-related complications can increase the risk of skin breakdown and impair the body's ability to heal once an ulcer develops. Diabetic foot ulcers may become infected, progress to deeper tissue involvement or osteomyelitis, and in severe cases contribute to lower-extremity amputation. Importantly, many diabetic foot ulcers are preventable through early identification of risk factors, appropriate foot surveillance, patient education, pressure reduction and offloading, and timely management of wounds and infections.
| A) | increasing bone density. | ||
| B) | enhancing inflammatory responses. | ||
| C) | reducing tissue perfusion and wound healing. | ||
| D) | improving oxygen delivery and circulation to the area |
Diabetic foot ulcers are a common and potentially serious complication of diabetes, arising from a combination of neurologic, vascular, and musculoskeletal abnormalities that impair the foot's ability to withstand and recover from repetitive stress or injury. Several factors substantially increase the risk of ulceration, particularly peripheral neuropathy, peripheral vascular disease, and Charcot foot. Less common factors include peripheral arterial disease, foot deformity, history of foot ulcerations, past amputation, poor vision, renal disease, and suboptimal glucose control [16]. Peripheral vascular disease can reduce tissue perfusion and impair wound healing, while Charcot foot causes progressive bone and joint destruction, deformity, and abnormal pressure distribution that can increase the risk of skin breakdown. Recognizing these risk factors is essential for identifying patients who require closer surveillance and implementing preventive interventions before an ulcer develops.
| A) | improves circulation. | ||
| B) | causes fungal infections. | ||
| C) | produces excessive sweating. | ||
| D) | creates deformity and abnormal pressure distribution. |
Diabetic foot ulcers are a common and potentially serious complication of diabetes, arising from a combination of neurologic, vascular, and musculoskeletal abnormalities that impair the foot's ability to withstand and recover from repetitive stress or injury. Several factors substantially increase the risk of ulceration, particularly peripheral neuropathy, peripheral vascular disease, and Charcot foot. Less common factors include peripheral arterial disease, foot deformity, history of foot ulcerations, past amputation, poor vision, renal disease, and suboptimal glucose control [16]. Peripheral vascular disease can reduce tissue perfusion and impair wound healing, while Charcot foot causes progressive bone and joint destruction, deformity, and abnormal pressure distribution that can increase the risk of skin breakdown. Recognizing these risk factors is essential for identifying patients who require closer surveillance and implementing preventive interventions before an ulcer develops.
| A) | It strengthens foot muscles. | ||
| B) | It improves circulation and tissue perfusion in the extremities. | ||
| C) | It reduces protective sensation, allowing injuries to go unnoticed. | ||
| D) | It increases perspiration of the feet, creating a moist environment for bacterial overgrowth. |
Neuropathy is one of the most common causes of diabetic foot ulceration [16]. It can diminish protective sensation and alter foot biomechanics, allowing repetitive trauma or minor injuries to go unnoticed. Patients with diabetes and neuropathy have a sevenfold increase risk of developing foot wounds compared with people with diabetes who are free from neuropathy [16]. More than 60% of those diagnosed with diabetes will go on to develop neuropathy [17]. It is especially prevalent in those who have had diabetes for more than 10 years and have poorly controlled blood glucose levels [18].
| A) | Amyotrophy | ||
| B) | Cranial neuropathy | ||
| C) | Autonomic neuropathy | ||
| D) | Distal symmetric polyneuropathy |
Diabetic neuropathy encompasses a group of nerve disorders caused by chronic hyperglycemia and other metabolic and vascular factors associated with diabetes. Although distal symmetric polyneuropathy (DSPN) is the most common form and is particularly important in the development of diabetic foot complications, diabetes can affect multiple types of nerves. The clinical presentation varies according to the nerves involved and may include sensory loss, pain, weakness, autonomic dysfunction, or focal neurologic deficits.
| A) | Claw toes | ||
| B) | Hallux valgus | ||
| C) | Isolated heel spur | ||
| D) | Pes planus (flatfoot) |
Motor neuropathy causes problems with ambulation, and over an extended period of time, patients with motor neuropathy can lose up to half of the muscle volume of their feet [18]. Common signs and symptoms include progressive muscle weakness, visible muscle atrophy, loss of deep tendon reflexes (e.g., Achilles reflex), poor balance, foot drop, and foot deformities (e.g., claw toes).
| A) | Allen test | ||
| B) | Snellen test | ||
| C) | Romberg test | ||
| D) | Monofilament test |
Loss of protective sensation is particularly important when evaluating the risk of diabetic foot ulceration. The 10-g monofilament test is commonly used to identify patients with clinically significant sensory loss. However, monofilament testing should generally be performed in combination with another assessment of sensory function, rather than being used as the sole diagnostic test [24].
| A) | immobility. | ||
| B) | high-protein diets. | ||
| C) | excessive exercise. | ||
| D) | poorly fitting footwear. |
It is estimated that up to 80% of diabetic foot ulcers are related to pressure from poorly fitting footwear [16]. As such, correctly fitting shoes are a mainstay in the prevention of foot injury for patients with diabetes and peripheral neuropathy [22]. Shoes should fit comfortably and should be correctly sized. Unwittingly, many individuals with peripheral neuropathy wear shoes that are too tight, because the reduced sensory function requires that footwear squeeze the feet before it is felt. Shoes should have an ample toe box that does not press down on the toes or squeeze them together from side to side [18].
| A) | PAD. | ||
| B) | cellulitis. | ||
| C) | Charcot foot. | ||
| D) | motor neuropathy. |
Neuropathy and PAD can produce different, but overlapping, foot findings. Autonomic neuropathy may cause reduced sweating and dry, cracked skin, whereas peripheral arterial disease may produce cool skin, diminished pulses, pallor with elevation, and dependent rubor. Because these conditions frequently coexist, a comprehensive diabetic foot examination should assess both neurologic and vascular status.
| A) | gout only. | ||
| B) | plantar fasciitis. | ||
| C) | Tinea pedis (athlete's foot). | ||
| D) | acute Charcot arthropathy. |
An acute Charcot foot can be mistaken for cellulitis, acute gouty arthritis, or thrombophlebitis [16,29]. A hot, red, swollen foot in a person with diabetes and peripheral neuropathy should be presumed to have acute Charcot arthropathy until it has been appropriately evaluated. The absence of significant pain does not exclude a serious underlying process. Persistent erythema, systemic symptoms, an open wound, elevated inflammatory markers, or other evidence of infection should increase concern for cellulitis or osteomyelitis. If swelling and redness abates with elevation of the affected extremity, Charcot foot is more likely than infection.
| A) | The patient who performs daily foot care | ||
| B) | The nurse who provides foot-care education | ||
| C) | The endocrinologist who manages diabetes | ||
| D) | The podiatrist who provides professional foot care |
The most important member of the team is the patient, and the goal of care is to empower them to take charge of their own foot health. Family members and the patient's support system will also play an important role, especially if the patient is unable to perform routine foot care and daily foot inspections.
| A) | Ankle-brachial index measurement | ||
| B) | Assessment of foot temperature and skin color | ||
| C) | Vibration perception using a 128-Hz tuning fork | ||
| D) | Evaluation of serum glucose and hemoglobin A1C levels |
Checking for loss of protective sensation is a cornerstone of the diabetic foot exam. The most common tests used in this assessment are [16]:
10-g monofilaments
128-Hz tuning fork
Ankle reflex testing
Pinprick sensation
Vibration perception threshold testing
At least two of these tests should be routinely done during a diabetic foot screening [16].
| A) | Apical and carotid | ||
| B) | Radial and brachial | ||
| C) | Temporal and carotid | ||
| D) | Femoral, popliteal, dorsalis pedis, and posterior tibial |
During the examination, the femoral, popliteal, and dorsalis pedis and posterior tibial artery pulses should be palpated [16]. Normally, clearly palpable posterior tibialis and dorsalis pedal pulses are a positive indication of adequate circulation [16].
| A) | Daily | ||
| B) | Weekly | ||
| C) | Monthly | ||
| D) | Only when symptoms occur |
Diabetic foot education should begin with the following instructions to patients [18,34,35]:
Check your feet every day for cuts, bruises, blisters, or swelling. A good time to do this is when you take your shoes off at the end of the day.
If you cannot see the soles of your feet, use a long-handle mirror or have someone else do the inspection for you.
Wash your feet every day. Dry them carefully, paying special attention to the areas between your toes. Do not soak your feet, as this can lead to dry skin.
Rub a small amount of a hydrating skin lotion into your feet after washing and drying. However, do not rub lotion between your toes. Choose a lotion that is alcohol free, because as alcohol evaporates it causes drying of the skin.
Use cornstarch or talcum powder between the toes, but do not use so much that it cakes.
Never go barefoot, even in your own home. Something as small as a sesame seed can cause enough pressure to start a foot ulcer. The only times you should not have protective footwear on is when you are bathing or in bed.
Choose seamless, lightly padded socks. Avoid tightly fitting socks. (Patients can buy specially made diabetic socks. They usually provide cushioning and reverse stitching on the toe seams to avoid friction and shear.)
Do not place elastic garters or rubber bands around your legs.
Protect your feet from heat and cold. Never put your feet into hot water. Use your hand to check the temperature of water before putting your feet into it.
Shake out shoes before putting them on, and feel along the inside of shoes for small hard objects that could cause pressure.
Make sure that the lining inside shoes or slippers is smooth and wrinkle free.
When sitting, put your feet up. Do not keep your legs crossed for long periods of time.
Practice wiggling your toes two to three times daily for about five minutes.
Avoid plastic or vinyl shoes, as they do not stretch or allow for air flow.
If you are wearing soft inserts in your shoes, these will need to be replaced three times yearly.
| A) | Soak feet daily for 30 minutes. | ||
| B) | Apply lotion between the toes. | ||
| C) | Shake out shoes before putting them on. | ||
| D) | Go barefoot indoors to strengthen foot muscles. |
Diabetic foot education should begin with the following instructions to patients [18,34,35]:
Check your feet every day for cuts, bruises, blisters, or swelling. A good time to do this is when you take your shoes off at the end of the day.
If you cannot see the soles of your feet, use a long-handle mirror or have someone else do the inspection for you.
Wash your feet every day. Dry them carefully, paying special attention to the areas between your toes. Do not soak your feet, as this can lead to dry skin.
Rub a small amount of a hydrating skin lotion into your feet after washing and drying. However, do not rub lotion between your toes. Choose a lotion that is alcohol free, because as alcohol evaporates it causes drying of the skin.
Use cornstarch or talcum powder between the toes, but do not use so much that it cakes.
Never go barefoot, even in your own home. Something as small as a sesame seed can cause enough pressure to start a foot ulcer. The only times you should not have protective footwear on is when you are bathing or in bed.
Choose seamless, lightly padded socks. Avoid tightly fitting socks. (Patients can buy specially made diabetic socks. They usually provide cushioning and reverse stitching on the toe seams to avoid friction and shear.)
Do not place elastic garters or rubber bands around your legs.
Protect your feet from heat and cold. Never put your feet into hot water. Use your hand to check the temperature of water before putting your feet into it.
Shake out shoes before putting them on, and feel along the inside of shoes for small hard objects that could cause pressure.
Make sure that the lining inside shoes or slippers is smooth and wrinkle free.
When sitting, put your feet up. Do not keep your legs crossed for long periods of time.
Practice wiggling your toes two to three times daily for about five minutes.
Avoid plastic or vinyl shoes, as they do not stretch or allow for air flow.
If you are wearing soft inserts in your shoes, these will need to be replaced three times yearly.
| A) | Exercise and massage | ||
| B) | Antibiotics and dressings | ||
| C) | Vitamin supplements and hydration | ||
| D) | Adequate circulation and pressure relief |
The two most important components in healing diabetic foot ulcers are adequate circulation and pressure relief. The first and possibly most important approach in the treatment of diabetic foot ulcers is off-loading [22,39]. This results in pressure being dispersed over a wider area of the foot and reduces the burden of mechanical stress on the wound, which is essential for healing [16].
| A) | Bed rest only | ||
| B) | Custom sandals | ||
| C) | Compression stockings | ||
| D) | Nonremovable knee-high offloading device |
Reducing pressure and shear forces at the ulcer site allows tissue to heal and helps prevent continued trauma to the wound. There is some evidence that off-loading with nonremovable devices achieves a higher level of healing than with removable devices [39]. Current guidelines recommend a nonremovable knee-high offloading device as the first-choice treatment for a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes. A total contact cast (TCC) or a nonremovable knee-high walker may be used, with the choice based on available resources, clinician expertise, patient-specific factors, and acceptability.
| A) | osteomyelitis. | ||
| B) | gangrene requiring amputation. | ||
| C) | systemic manifestations of infection. | ||
| D) | local signs of inflammation, with erythema extending no more than 2 cm from the wound. |
The IWGDF/IDSA classification categorizes infection according to its severity [31]. A mild infection involves at least two local signs of inflammation with erythema extending no more than 2 cm beyond the wound margin and no systemic manifestations. A moderate infection involves deeper tissues and/or erythema extending 2 cm or more beyond the wound margin, without systemic inflammatory response. Severe infection is characterized by local infection accompanied by systemic manifestations of infection.
| A) | They impair circulation. | ||
| B) | They worsen neuropathy. | ||
| C) | They promote wound dehydration. | ||
| D) | They are not indicated solely to promote healing. |
Antibiotics should not be used to treat a clinically uninfected diabetic foot ulcer or simply to promote wound healing [31]. Instead, antibiotic therapy should be reserved for wounds with clinical evidence of infection.
| A) | 10% | ||
| B) | 20% | ||
| C) | 40% | ||
| D) | 80% |
Re-occurrence of diabetic foot ulcers is a major problem, with approximately 40% of patients who have successfully healed a diabetic foot ulcer experience another ulcer within one year, increasing to approximately 65% within three years [16,44]. The use of custom-made footwear appears to play a protective role in preventing additional ulceration [16]. After a diabetic foot ulcer has healed, the patient should not go back to wearing the shoes (or similar shoes) that they were wearing at the time the ulcer developed. Regular shoes are not made to accommodate irregularities in foot shape and at-risk pressure points.