Utilizing Risk Categories to Improve Meaningful Diabetic Foot Referrals

20.8 million Americans have been diagnosed with diabetes. As the diabetes population continues to grow, many people are being diagnosed late, often not until there is a serious but possibly avoidable complication. Many of our patients, especially type II patients, do not take the disease seriously and do not manage their disease properly. As a result, late detection or poor management can spell disaster in relation to potential foot problems such as ulceration, amputation, and Charcot changes and deformities.

The majority of the diabetes population is not managed by Foot and Ankle specialists, i.e.: Podiatrists or Orthopedists, but by General Practice Physicians, doctors who certainly understand diabetes, but not necessarily the multitude of things that can put the diabetic foot at risk. Unfortunately, in this fast paced world of medicine, many people with diabetes never have their feet examined except when there is a problem, and that is often too late.

Major categories that must be taken into consideration when assessing risk categories would include, sensory testing, vascular considerations, skin conditions including ulcerations, and finally deformities, which can be anything from a hammer toe to charcot deformities or amputations.

Physicians can and do certainly recognize and diagnose these types of issues, but don’t necessarily understand what, if anything can be done conservatively or pedorthically to protect the feet and avoid future problems.

This presentation is set in place according to a prevention program started by the Gillis W. Long Hansen’s Disease Center. Joseph Reed, RPT, presented the basic concept for this program in 1982. Reed believed that patients could be categorized according to their potential risk of injury. Patients with the need for the most protective foot wear, would be seen with the most frequency, and would carry the highest risk category.

A clinician’s ability to assess or determine the presence or absence of protective levels of sensation, peripheral vascular disease, or both is what the system of risk determination is based upon. For this purpose, protective levels of sensation are present when a person can feel and react to a threatening stimulus with a response to prevent injury.

The risk categories are broken into four levels; risk category zero thru risk category three. Risk category zero consists of patients who have been diagnosed with Diabetes, and have protective levels of sensation in their feet. Because loss of sensation and vascular supply to the foot can be lost at any time during the disease, and can be gradual, many times it goes completely unnoticed by the patient. A sensory test should be done periodically to determine the degree of sensation the patient retains.

Risk category one patients have a higher risk of injury because they have begun to lose protective levels of sensation in their feet. These patients have not yet had ulcers, but just walking could cause damage to their feet. Patients who do not feel the 5.07 Semmes-Weinstein monofilament that bends with a pressure of 10g would be placed into risk category one.

Risk category two consists of diabetic patients who have a foot deformity, have lost protective sensation, but have not developed an ulcer. The deformity is usually as a result of a concentration of stress in a very small area in the foot. This area of the foot is usually not used to an area of pressure, which results in an injury.

Risk category three consists of patients that have both lost protective sensation and have a history of foot ulceration. An area of the foot that has developed an ulcer is more susceptible to forming a repeat ulcer in the same area of the soft tissues.

Management of these risk categories include, Category zero which amounts to education and counseling and includes discussion of shoe fitting size, width, and shoe shape. Patients need to understand simple shoe construction; types of upper and soling materials and when shoes are worn out and need to be replaced.

Category one management requires more input from professionals. The patient now has less protective sensation. Someone skilled in Foot and Shoe evaluation (Pedorthist, Orthotists, etc.) needs to evaluate the foot, measure and fit the patients feet properly, and provide some sort of protective insole, pre-made or custom as needed.

Category two requires more sophisticated prescription footwear to avoid further ulceration. Footwear would include Indepth shoes, custom foot orthoses, shoe modifications, and possibly custom shoes.

Finally, category three provides the most accommodation and protection for the foot most at risk. Everything from category two, plus heat moldable shoes, custom healing sandals, and possibly lower limb orthoses and prostheses could be used to treat the patient in this category.

Often if physicians don’t know what to prescribe, they tend not to prescribe anything at all! Using the attached table and presenting it to your referral sources in any Way possible will give physicians an easy, understandable way of referring their patents to your facility.