Obesity and the Diabetic Foot

CPD Module

Obesity and the diabetic foot

Fran Game

Citation: Game F (2013) Diabetic foot disease is a serious and expensive problem, nationally and Obesity and the diabetic foot. Diabesity in Practice 2: 112–7 internationally, affecting about 2.5% of people with diabetes at any one time. It is not, however, a single entity but encompasses pathologies such as diabetic Article points neuropathy, peripheral arterial disease, foot ulceration and Charcot neuropathic 1. The diabetic foot is a spectrum of disorders ranging from feet osteoarthropathy. People with diabetes who are obese may be at particular risk “at risk” from the effects of owing to the increased chance of peripheral neuropathy, peripheral arterial disease peripheral arterial disease and neuropathy, to the ulcerated and inability to self-care. The management of foot ulceration is complex, requiring foot and acute Charcot input from several different specialities. People with diabesity are best served, neuropathic osteoarthropathy. therefore, by rapid referral to the expert multi-disciplinary foot care team. This 2. It is clear that a number of different specialists are article reviews the aetiology and management of the diabetic foot, highlighting required to manage all of areas where obesity may present particular clinical challenges. the different facets of the disease, and for this reason the diabetic foot is best managed by rapid referral to a multi- he readership of this journal does not figure at around £650 million per year in the UK disciplinary foot care team. need reminding that parts of the world are (Kerr, 2012). The personal costs to the affected 3. People with diabetes who facing the dual, and often overlapping, individuals are even higher. Quality of life is are obese pose a particular T epidemics of obesity and type 2 diabetes. reported as being worse for individuals with an challenge in their ability to The inevitable outcome of this is that, despite active foot ulcer than those with other chronic self-care to prevent disease, in the associated changes in improvements in the management of diabetes, diseases such as chronic obstructive pulmonary risks and prognosis, and in the there is still likely to be a disturbing increase disease (Kerr, 2012), and lower still if a person choice of diagnostic tests. in the number of people suffering from the long- has a major amputation (Ragnarson Tennvall and term complications of the disease. One of the most Apelqvist, 2000). Key words disabling of these complications is foot disease. - Diabetic foot Risk factors for the development - Obesity - Peripheral arterial disease Diabetic foot disease – of diabetic foot disease - Peripheral neuropathy the scale of the problem People with peripheral sensory neuropathy, - Self-care Current UK estimates are that approximately 2.5% arteriopathy and deformity are among those most of people with diabetes will have a foot ulcer at any likely to develop foot ulceration (Abbott et al, time, with a further 2.5% having had a previous 2002), and it is these items that are at the core of foot ulcer (Kerr, 2012). This means that at present the screening programme for “at risk” feet in the around 61 000 people with diabetes are estimated UK via the Quality and Outcomes Framework to have a foot ulcer within the UK. It is also well incentive scheme for general practitioners (NHS known that the risk of lower-extremity amputation Commissioning Board et al, 2013). (either major [above ankle] or minor [below ankle]) is around 20 times higher in people with diabetes Peripheral neuropathy than those without the condition (Kerr, 2012) and Whilst it is peripheral sensory neuropathy which Author that 85% of all amputations are preceded by foot is tested during screening for the “at risk” foot, Fran Game is a Consultant ulceration (Mayfield et al, 1998). motor and autonomic neuropathy also frequently Diabetologist, Derby The cost of diabetic foot disease is vast, if co-exist. The presence of sensory neuropathy means Hospitals NHS Trust, and an Honorary Associate Professor, both management of ulcers and amputations that an individual can traumatise the foot without University of Nottingham. are taken into account; a recent estimate put the being aware, whereas motor neuropathy leads to

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muscle atrophy, foot deformity and altered pressure with diabetes further increase their risk if they Page points distribution across the foot, predisposing the foot to develop renal disease, and this is independent of 1. Obesity per se, as well as ulceration. Autonomic neuropathy leads to altered other known risk factors (O’Hare et al, 2002). hypertriglyceridaemia, may regulation of cutaneous blood flow, the loss of directly increase the risk of the development of peripheral sweating and hence dry, fragile skin that is prone to Triggers of ulceration neuropathy independently cracking and fissures. Whilst neuropathy and PAD undoubtedly put the of glucose control. Neuropathy is, of course, one of the person with diabetes at risk of the development 2. This finding of a possible “microangiopathic” complications of diabetes and of foot disease, the precipitating event is usually independent role of obesity in peripheral neuropathy risk the risk of the development of this complication is traumatic in origin. In the North-West Diabetes adds even greater significance related to glycaemic control (American Diabetes Foot Care Study (Abbott et al 2002), in over half the to the need to treat weight Association, 2000). There are other factors, participants the precipitating traumatic event was as well as type 2 diabetes in people with diabesity. however, that may impinge upon the background of related to inappropriate or ill-fitting footwear. This 3. The increased risk of the diabetes and make the development of neuropathy can be a particular problem in people with comorbid development of peripheral more likely. In the UK, among the most commonly obesity, who may have significant problems buying arterial disease along with seen such factors are the consumption of excess shoes that provide a good fit. Individuals with other macrovascular diseases in people with type 2 diabetes alcohol and vitamin B deficiency (NHS Choices, markedly reduced mobility may also be at risk of the 12 and obesity is well recognised. 2012). Recently, the use of metformin has been development of pressure ulcers, particularly on the 4. The precipitating traumatic recognised as a possible iatrogenic cause for heels in my experience. event for ulceration is often exacerbation of peripheral neuropathy through related to inappropriate or its effects on vitamin B metabolism. It is not Visual disturbance and self-care. ill-fitting footwear; this can 12 be a particular problem in currently recommended that metformin be Owing to the shared pathogenic mechanisms, people with comorbid obesity, discontinued, as the resulting areas of benefits diabetic retinopathy and other complications who may have significant from metformin’s effect on glycaemic control are of diabetes frequently co-exist. It has long been problems buying shoes that provide a good fit. wider than just neuropathy (Wile and Toth, 2010). appreciated that visual acuity is an important 5. For people who are obese, However, measuring vitamin B12 levels in people prerequisite for the ability to perform self-foot challenges of inspection and on long-term metformin therapy in whom there inspection and good self-care (Thompson and other elements of self-care is evidence of worsening of neuropathy may be Masson, 1992). However, for people who are obese, may be compounded by limited flexibility and the challenges of inspection and other elements of self- of benefit. inability to wash, or look at, Obesity per se, as well as hypertriglyceridaemia, care may be compounded by limited flexibility their feet on a daily basis. may directly increase the risk of the development and the inability to wash, or look at, their feet on a of peripheral neuropathy independently of glucose daily basis, as recommended by the Diabetes UK control. There may be differential effects on Putting Feet First campaign (Diabetes UK, 2012). the small fibres compared with the large fibres, When discussing foot inspection and self-care, it with the latter seeming to be more affected by is important to recognise individuals’ limitations hyperglycaemia (Smith and Singleton, 2013). This and help put alternative mechanisms into place finding of a possible independent role of obesity if necessary. For example, other members of the in peripheral neuropathy risk adds even greater household could be asked to help with foot washing, significance to the need to treat weight as well as or a mirror could be used to look at the plantar type 2 diabetes in people with diabesity. aspect of the foot, if the individual has difficulty with flexibility. Peripheral arterial disease Around one in six people with type 2 diabetes may Activity levels have peripheral arterial disease (PAD) at diagnosis Obesity can be both a consequence and a cause of and this proportion rises to around half in those low levels of physical activity. It is often assumed with comorbid foot ulceration (Hinchliffe et al, that a person who does not walk much is at a lower 2012). The increased risk of the development of risk of foot ulceration than one who is more active. PAD along with other macrovascular diseases This may not be the case; one study of a series of in people with type 2 diabetes and obesity is well individuals with neuropathy showed that it was recognised (e.g. Standl, 2012). In addition, people the people who took the least number of steps

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Page points per day who were at the highest risk of ulceration probe by suitably trained individuals within the 1. People with reduced (Armstrong et al, 2004). What was most remarkable clinic setting. The demonstration of a triphasic mobility should be warned about this study, however, was the finding that it waveform in peripheral pulses can effectively against sudden bursts of was the variability of daily activity which posed the exclude significant arterial disease in >90% of limbs unaccustomed activity. highest risk for the development of foot ulceration. (Williams et al, 2005). People thought to have PAD 2. Perception of the presence of peripheral pulses can be People with reduced mobility should therefore be who have an open ulcer need urgent assessment by a subjective and influenced warned against sudden bursts of unaccustomed vascular surgeon. by many external factors, activity. including obesity. Management of the effect 3. Recent guidelines from the International Working Management of the established ulcer of neuropathy: “Offloading” Group of the Diabetic Foot The same pathological mechanisms – neuropathy It is not so much the neuropathy that needs recommend the use of non- and ischaemia – that are responsible for the foot managing in an individual presenting with a removable offloading, such as a total contact cast, as the (or feet) of a person with diabetes being “at risk” neuropathic ulcer as the effect of the neuropathy on first-line treatment option. for the development of ulcers are also frequently that person’s response to ulceration. An insensate 4. If a total contact cast is not responsible for the failure of a wound to heal (Ince foot can allow an individual to continue to mobilise an option, various off-the- et al, 2008). Infection rarely precipitates ulceration on an ulcerated area, if it is plantar in location, shelf below-knee walkers are as the skin usually provides an effective barrier and to do so in inappropriate footwear. This can available, but particular care may be needed in ensuring an against bacterial invasion (except in the case of cause ongoing trauma to the area and prevent appropriate fit for an obese tinea pedis, which causes breaks in the skin) but healing. Reducing foot pressures, or “offloading”, person, and in some cases a frequently complicates it and may also prolong the is fundamental to the healing of neuropathic foot good fit may not be achievable. period needed for healing (Prompers et al, 2008). ulcers. Many different devices are available but The relative contribution of each of these pathologies their capacity to offload the diabetic foot is variable. varies from individual to individual, and from ulcer Recent guidelines from the International Working to ulcer. As described below, obesity is an important Group of the Diabetic Foot recommend the use of factor contributing to this variation. non-removable offloading, such as a total contact cast, as the first-line treatment option (Bakker Arterial assessment et al, 2012). The findings from a simple palpation of pulses has If a total contact cast is not an option, various off- been shown in clinical studies to correlate with the-shelf below-knee walkers are available. Particular outcome (Aubert et al, 2013), but perception of care may be needed in ensuring an appropriate fit for the presence of peripheral pulses can be subjective an obese person, and in some cases a good fit may and influenced by many external factors, including not be achievable. If it is, though, and these walkers obesity. Given the frequency of arterial disease in can be rendered non-removable – in order to enforce people with diabetes and the difficulty of pulse compliance – outcome healing rates are improved palpation in a substantial number of individuals, (Armstrong et al, 2005). The offloading capacity a case has been made for every person presenting of normal shoes or therapeutic footwear, although with a foot ulcer to have an ankle–brachial important for the prevention of foot ulcers, is not pressure index (ABPI) measured as part of the usually sufficient for the healing of neuropathic initial work-up. While an ABPI of <0.9 definitely ulcers, especially when so many other devices have indicates ischaemia, calcification of the arteries been shown to be effective. in diabetes (associated with neuropathy as well as renal impairment [Jeffcoate et al, 2009]) will cause Infection elevation of the ratio even within the normal range Not only is infection of a foot ulcer negatively (Aubert et al, 2013). Thus, an ABPI measurement associated with healing, it also considerably increases has poor sensitivity to pick up significant arterial the risk of hospitalisation and amputation (Lavery disease in people with diabetes. et al, 2007). The diagnosis of clinical infection is Doppler arterial waveform is another non- based on signs of inflammation (erythema, warmth, invasive tool used to assess the vascular status, tenderness, pain or induration), although these may and it can be performed with a hand-held Doppler be blunted in people with PAD (Lavery et al, 2007).

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Clinically non-infected wounds, even if there is up against a combination of those associated with Page points surface contamination, should not be treated with surgery and the risk of development of new ulcers 1. NICE guidelines suggest that antibiotics, to avoid the emergence of multi-drug- on the foot if its architecture is altered (so-called if osteomyelitis is suspected resistant organisms. “transfer ulcers”). Patient preference should also be and a plain film is unhelpful then an MRI scan should There is unfortunately no good evidence from taken into account here. be performed as this has a randomised trials showing the superiority of any sensitivity of around 90% and particular antibiotic regimen above any other for Charcot neuropathic osteoarthropathy specificity of about 80%. the management of clinically infected lesions, Charcot neuropathic osteoarthropathy, commonly 2. MRI scanners do have size limitations, however. The and so choices should be made locally, in the referred to as the “Charcot foot”, is a condition usual width limit is 60 cm, knowledge of likely pathogens and known antibiotic affecting the bones, joints and soft tissues of the foot which might exclude some resistance patterns. Although some infections are and ankle, which is characterised by inflammation obese individuals. A labelled white cell scan may be helpful polymicrobial, gram-positive cocci are usually the in the earliest phase (Rogers et al, 2011). A in these circumstances. predominant organisms and empirical antibiotic complication of peripheral neuropathy, it can be seen 3. It is often thought that obesity regimens should take this into account (Lipsky et in individuals with causes of peripheral neuropathy may play a part in the onset al, 2012). For mild soft tissue infection 7–10 days’ other than diabetes, although diabetes is still the of the disease because of the increase in forces applied to treatment should be adequate, with more serious or leading cause in the UK. It is currently thought the foot and ankle. A consensus deeper infections requiring longer. that the uncontrolled release of pro-inflammatory is yet to emerge on this, cytokines (especially interleukin-1 beta and tumour and the available evidence Osteomyelitis necrosis factor-alpha [Jeffcoate et al, 2005]) is somewhat conflicting. If, in the presence of an infected wound, bone is following minor trauma or inflammatory insult by visible at the base or can be felt when the wound is another cause (including infection or surgery [Game gently probed with a sterile instrument (i.e. a positive et al 2012]), along with continued mobilisation on “probe-to-bone test” result) then osteomyelitis is an insensate foot, leads to ongoing bone destruction, likely. In a non-infected wound, however, a positive subluxation, dislocation and eventual deformity. probe test result does not mean that bone infection is Diagnosis is clinical in the first instance and necessarily present (Lipsky et al, 2012). healthcare professionals must be alert to people The diagnosis of osteomyelitis is often difficult with neuropathy from any cause presenting with and can be made more problematic by the fact that a unilateral inflamed foot. If the person continues X-rays may be persistently unchanged (loss of visible to mobilise while investigations are being pursued, cortex on a plain film only occurs after 30–50% of further bony damage may occur (Caputo et al, 1998). bone mineral has been lost) or that changes may be It is often thought that obesity may play a part difficult to distinguish from those seen in Charcot in the onset of the disease because of the increase neuropathic osteoarthropathy (covered later). NICE in forces applied to the foot and ankle. A consensus (2011) guidelines suggest that if osteomyelitis is is yet to emerge on this, but a recent case–control suspected and a plain film is unhelpful then an MRI study investigated the relationship between elevated scan should be performed as this has a sensitivity of BMI and the development of acute Charcot around 90% and specificity of about 80% (Dinh neuroarthropathy in people with diabetes and found et al, 2008). MRI scanners do have size limitations, no statistically significant association (Ross et al, however. The usual width limit is 60 cm, which 2013). might exclude some obese individuals. A labelled white cell scan may be helpful in these circumstances Diagnosis (NICE, 2011). X-rays may be normal in the first instance, show The choice of primarily medical (i.e. antibiotics subtle fractures and dislocations or later show alone) as opposed to primarily surgical treatment of more overt fractures and subluxations. If the X-ray osteomyelitis of the diabetic foot is controversial, but is normal, an MRI scan should be performed if studies have shown that infection can be successfully possible. If not, a triple-phase bone scan has a similar eradicated with antibiotics alone in 60–80% of cases sensitivity to MRI but is less specific. Computerised (Game, 2010). The risks associated with prolonged tomography scanning may be better at revealing antibiotic therapy (6–8 weeks) must be weighed microfractures that were not apparent on plain X-ray

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but will not show the bone oedema associated with Diabetes UK (2012) Putting Feet First. Diabetes UK, London. Available “People with diabetes at: http://bit.ly/12KbcmH (accessed 28.08.13) active disease (Rogers et al, 2011). who are obese pose a Dinh MT, Abad CL, Safdar N (2008) Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying particular challenge in diabetic foot ulcers: meta-analysis. Clin Infect Dis 47: 519–27 Management Game F (2010) Management of osteomyelitis of the foot in diabetes their ability to self-care Offloading is the most important management mellitus. Nat Rev Endocrinol 6: 43–7 Game FL, Catlow R, Jones GR et al (2012) Audit of acute Charcot’s to prevent disease, in strategy for the acute Charcot foot and can arrest disease in UK: the CDUK study. Diabetologia 55: 32–5 the associated changes the progression to deformity. Ideally, the foot should Hinchliffe RJ, Andros G, Apelqvist J et al (2012) A systematic review be immobilised in a non-removable cast or walker of the effectiveness of revascularization of the ulcerated foot in in risks and prognosis, patients with diabetes and peripheral arterial disease. Diabetes (Rogers, 2011). If possible, the person with the Metab Res Rev 28(Suppl 1): 179–217 and in the choice of Ince P, Abbas ZG, Lutale JK et al (2008) Use of the SINBAD condition should also use crutches or a wheelchair classification system and score in comparing outcome of foot ulcer diagnostic tests.” and should be encouraged to avoid weight-bearing management on three continents. Diabetes Care 31: 964–7 Jeffcoate WJ, Game F, Cavanagh PR (2005) The role of proinflammatory on the affected side. Casting should be continued cytokines in the cause of neuropathic osteoarthropathy (acute until the temperature difference between the two Charcot foot) in diabetes. Lancet 366: 2058–61 Jeffcoate WJ, Rasmussen LM, Hofbauer LC, Game FL (2009) Medial feet has settled (Rogers, 2011). arterial calcification in diabetes and its relationship to neuropathy. Diabetologia 52: 2478–88 Kerr M (2012) Foot Care for People with Diabetes: The Economic Case Conclusion for Change. NHS Diabetes, Newcastle Upon Tyne. Available at: The diabetic foot is not one single entity but a http://bit.ly/18ZOuId (accessed 28.08.13) Lavery LA, Armstrong DG, Murdoch DP et al (2007). Validation of spectrum of disorders ranging from feet “at risk” the Infectious Diseases Society of America’s diabetic foot infection from the effects of PAD and neuropathy, to the classification system. Clin Infect Dis 44: 562–5 Lipsky BA, Berendt AR, Cornia PB et al (2012) 2012 Infectious Diseases ulcerated foot and acute Charcot neuropathic Society of America clinical practice guideline for the diagnosis and osteoarthropathy. The spectrum of disorders is costly treatment of diabetic foot infections. Clin Infect Dis 54: 132–73 Mayfield JA, Reiber GE, Sanders LJ et al (1998) Preventive foot care in to the UK health economy, as it is to the person people with diabetes. Diabetes Care 21: 2161–77 with the condition, and it is clear that a number of NICE (2011) Diabetic foot problems – inpatient management (CG119). NICE, London. Available at: http://guidance.nice.org.uk/cg119 different specialists are required to manage all of the (accessed 28.08.13) different facets of the disease. It is for this reason that NHS Choices (2012) Causes of peripheral neuropathy. Available at: the diabetic foot is best managed by rapid referral to http://bit.ly/1d9QB0X (accessed 28.08.13) NHS Commissioning Board, British Medical Association, NHS a multi-disciplinary foot care team. Employers (2013) Quality and Outcomes Framework guidance for GMS contract 2013/14. NHS, London. Available at: http://bit.ly/ People with diabetes who are obese pose a Xk1mq1 (accessed 28.08.13) particular challenge in their ability to self-care to O’Hare AM, Hsu CY, Bacchetti P et al (2002) Peripheral vascular disease risk factors among patients undergoing haemodialysis. J Am prevent disease, in the associated changes in risks Soc Nephrol 13: 497–503 and prognosis, and in the choice of diagnostic tests. n Osterhoff G, Böni T, Berli M (2013) Recurrence of acute Charcot neuropathic osteoarthropathy after conservative treatment. Foot Ankle Int 34: 359–64 Prompers L, Schaper N, Apelqvist J et al (2008) Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences Abbott CA, Carrington AL, Ashe H et al (2002) The North-West between individuals with and without peripheral arterial disease. Diabetes Foot Care Study: incidence of, and risk factors for, new The EURODIALE Study. Diabetologia 51: 747–55 diabetic foot ulceration in a community-based patient cohort. Diabet Med 19: 377–84 Ragnarson Tennvall G, Apelqvist J (2000) Health-related quality of life in patients with diabetes mellitus and foot ulcers. J Diabetes American Diabetes Association (2000) Implications of the United Complications 14: 235–41 Kingdom Prospective Diabetes Study. Diabetes Care 23(Suppl 1): S27–31 Rogers LC, Frykberg RG, Armstrong DG et al (2011) The Charcot foot in diabetes. Diabetes Care 34: 2123–9 Armstrong DG, Lavery LA, Holtz-Neiderer K et al (2004) Variability in activity may precede diabetic foot ulceration. Diabetes Care 27: Ross AJ, Mendicino RW, Catanzariti AR (2013) Role of body mass 1980–4 index in acute charcot neuroarthropathy. J Foot Ankle Surg 52: 6–8 Armstrong DG, Lavery LA, Wu S, Boulton AJ (2005) Evaluation of Smith AG, Singleton JR (2013) Obesity and hyperlipidemia are risk removable and irremovable cast walkers in the healing of diabetic factors for early diabetic neuropathy. J Diabetes Complications foot wounds: a randomized controlled trial. Diabetes Care 28: 31 May [Epub ahead of print] 551–4 Standl E (2012) Dysglycemia and abdominal obesity. Curr Vasc Aubert C, Cluzel P, Kemel S et al (2013) Relationship between Pharmacol 10: 678–9 peripheral vascular calcification and accuracy of pulse palpation Thomson FJ, Masson EA (1992) Can elderly diabetic patients co- and ankle brachial index as screening methods for peripheral operate with routine foot care? Age Ageing 21: 333–7 arterial occlusive disease in patients with diabetes. Diabet Med (in Wile D, Toth C (2010) Association of metformin, elevated press) homocysteine, and methylmalonic acid levels and clinically Bakker K, Apelqvist J, Schaper NC (2012).Practical guidelines on the worsened diabetic peripheral neuropathy. Diabetes Care 33: management and prevention of the diabetic foot 2011. Diabetes 156–61 Metab Res Rev 28(Suppl 1): 225–31 Williams DT, Harding KG, Price P (2005) An evaluation of the efficacy Caputo GM, Ulbrecht J, Cavanagh PR, Juliano P (1998) The Charcot of methods used in screening for lower-limb arterial disease in foot in diabetes: six key points. Am Fam Physician 57: 2705–10 diabetes. Diabetes Care 28: 2206–10

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Online CPD activity Visit www.diabetesonthenet.com/cpd to record your answers and gain a certificate of participation Participants should read the preceding article before answering the multiple choice questions below. There is ONE correct answer to each question. After submitting your answers online, you will be immediately notified of your score. A pass mark of 70% is required to obtain a certificate of successful participation; however, it is possible to take the test a maximum of three times. A short explanation of the correct answer is provided. Before accessing your certificate, you will be given the opportunity to evaluate the activity and reflect on the module, stating how you will use what you have learnt in practice. The CPD centre keeps a record of your CPD activities and provides the option to add items to an action plan, which will help you to collate evidence for your annual appraisal.

1. Which SINGLE percentage represents the A. 10% 8. A 79-year-old woman with type 2 number of lower leg amputations in people B. 25% diabetes has an infected foot ulcer. with diabetes that are PRECEDED by foot C. 33% She has no known allergies. ulceration? Which ONE of the following, if any, D. 50% Select ONE option only. is the SINGLE MOST evidence-based E. 75% A. 10% antibiotic to offer her? B. 25% Select ONE option only. C. 50% 5. According to Diabetes UK, how A. Amoxicillin D. 85% frequently should people with diabetes B. Clindamycin E. 99% routinely check their feet? C. Erythromycin Select ONE option only. D. Flucloxacillin E. Phenoxymethylpenicillin 2. Which SINGLE ONE of the following A. Twice daily F. None of the above medications potentially EXACERBATES pre- B. Once daily existing diabetic peripheral neuropathy? C. Five days a week Select ONE option only. D. Once weekly 9. A 49-year-old obese man with type 2 diabetes has an infected ulcer on his A. Aspirin E. Once a month left fourth toe with a positive “probe- B. Isosorbide mononitrate to-bone” test. A foot X-ray is reported C. Metformin 6. A 63-year-old man with type 2 diabetes as normal. D. Ramipril and a history of mild PAD has an open According to NICE guidance, which E. Simvastatin ulcer on his right hallux. A recent ONE of the following is the MOST doppler ABPI is 1.1 bilaterally. appropriate NEXT investigation to Which ONE of the following is the confirm or refute the possibility of 3. A 57-year-old man with increasingly SINGLE MOST appropriate osteomyelitis? painful diabetic neuropathy takes the management option? Select ONE option only. following medication: aspirin, isosorbide Select ONE option only. mononitrate, metformin, ramipril and A. Bone scan simvastatin. A. Refer to chiropody B. CT scan Measuring the levels of which ONE of the B. Refer to orthotist C. Labelled white cell scan following may be the most relevant in this C. Refer to podiatrist D. MRI E. Ultrasound situation? D. Refer to tissue viability nurse Select ONE option only. E. Refer to a multi-disciplinary foot clinic A. Ferrous sulphate 10. A 61-year-old woman is diagnosed B. Folate with an acute right Charcot foot and C. Magnesium 7. A 59-year-old obese woman with type 2 immobilisation is advised. diabetes has a neuropathic foot ulcer. D. Vitamin B Select ONE option only. 12 Which ONE of the following is the E. Zinc A. 6 weeks SINGLE MOST evidence-based form B. 12 weeks of offloading? C. Until there is no temperature 4. Which SINGLE percentage represents Select ONE option only. difference between both feet the estimated number of people with A. Grade 3 compression hosiery type 2 diabetes and a foot ulcer who have D. Until the person reports no B. Moulded insoles pain on weight-bearing underlying peripheral arterial disease C. Orthotic designed shoes E. Until follow-up foot (PAD)? D. Removable below-knee walker X-rays are reported Select ONE option only. E. Total contact cast as normal

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