The spectrum of missed lower limb clinical findings at a diabetes clinic in KwaZulu-Natal: red flags for costly complications

Figures & data

Table 1: Medical and sociodemographic profile of the patient sample

Variables (n = 301)	Characteristics	Frequency	Percentage (%)
Number of years since diagnosis of diabetes	1–5	86	28.6
	6–10	64	21.3
	11–15	62	20.6
	16–20	28	9.3
	21–25	16	5.3
	26–30	11	3.7
	31–35	8	2.7
	Missing entries	26	8.6
Type of diabetes mellitus	Type I	39	13.0
	Type II	251	83.4
	Missing entries	11	3.7
Family history	No	87	28.9
	Yes	150	49.8
	Missing entries	64	21.3
Gender	Male	78	25.9
	Female	219	72.8
	Missing entries	4	1.3
Ages (grouped)	10–19	8	2.7
	20–29	10	3.3
	30–39	27	9.0
	40–49	46	15.3
	50–59	84	27.9
	60–69	86	28.6
	70–79	31	10.3
	80–89	7	2.3
	90–99	2	0.7
Employed	No	95	31.6
	Yes	44	14.6
	Pensioner	72	23.9
	Scholar	8	2.7
	Prisoner	1	0.3
	Missing entries	81	26.9
Racial composition	Black African	291	96.7
	White African	1	0.3
	Indian heritage	4	1.3
	Mixed heritage	4	1.3
	Missing entries	1	0.3
Body mass index	Underweight	4	1.3
	Normal weight	30	10.0
	Overweight	58	19.3
	Class I obese	75	24.9
	Class II obese	104	34.6
	Missing entries	30	10.0
Hypertensive	No	56	18.6
	Yes	233	77.4
	Missing entries	12	4.0
Hyperlipidaemic	No	33	11.0
	Yes	255	84.7
	Missing entries	13	4.3
eGFR (grouped)	< 60	88	29.2
	≥ 60	179	59.5
	Missing entries	34	11.3

Table 2: Dermal findings by podiatrist, missing from diabetes clinic notes

Dermal observations by podiatrist	n	“Red flag” relative importance	Suggested management, missing
Ulcer, untreated under 5th MTPJ (patient unaware)	1	High-risk amputation	Debridement by podiatrist, reduction, dressing, offloading device or intervention, education of patient and medical personnel, footwear assessment
Ulcer untreated under 1st MTPJ (patient unaware)	3	High-risk amputation	Debridement by podiatrist, reduction, dressing, offloading device or intervention, education of patient and medical personnel, footwear assessment
Ulcer: dry gangrene (unprotected)	1	High-risk amputation	Offloading device or intervention, dressing, education of patient and medical personnel, footwear assessment, protective device, vascular investigation
Ulcers, plantar, patient unaware	4	High-risk amputation	Debridement by podiatrist, reduction, dressing, offloading, education, footwear assessment
Ulcer open (patient aware) but no dressing used, no offloading	3	Infection, amputation	Debridement by podiatrist, reduction, dressing, offloading device or intervention, education of patient and medical personnel, footwear assessment
Ulcer under foot, unaware, no dressing used, no offloading	3	Infection, amputation	Debridement by podiatrist, reduction, dressing, offloading device or intervention, education of patient and medical personnel, footwear assessment
Ulcer, medial heel, no ulcer dressing or pressure relief	1	High-risk amputation	Debridement by podiatrist, reduction, dressing, offloading device or intervention, Wound care education, follow up. The patient should be offloading on crutches or moon boot
Ulcer, new, amputee, dressed by Eshane Clinic but no offloading	1	Impeded healing, amputation	Debridement and vascular assessment by podiatrist, reduction, offloading device or intervention, education of patient and medical personnel, footwear assessment
Incurvated nails Hx DVT	4	If not corrected, nail will encircle the nail tuft, resulting in ischaemic tip, gangrene; ulcer risk	Regular preventative treatment by podiatrist to re-shape nail margins; nail plate ‘Keriflex’ type nail prosthetic to be made by podiatrist to guide straight nail growth. Total nail removal contraindicated
Non-healed amputation site (> 1year duration)	2	Receded blood flow	Vascular workup, patient wound care education, follow-up. Patient should be offloading, e.g. on crutches
Hippocratic nails Hx smoking	1	Sign of potential pulmonary pathology	Screening chest radiograph
Indurated skin at ankle	1	Lipodermatosclerosis	Compression therapy arterial status permitting, fibrinolytic medication cardiac status permitting, potent anti-inflammatory topicals and steroids such as clobetasol propionate
Pre-tibial necrobiosis lipoidica diabeticorum	3	High risk of broken skin, Ulcer risk	Topical retinoids, topical steroids, PUVA light therapy, patient education on protecting the skin
Severe anhidrosis despite use of basic emollients	5	Dry, broken skin increases risk of infection; investigate neural involvement (sympathetic nervous system), ulcer risk	Next level keratinolytic balms (podiatrist to advise compounding pharmacist in hospital), education, e.g. advise no foot soaking, Rx neural supportive medication/supplementation, DDx dry scaly tinea, obtain skin specimen for pathology test
Hyperhidrotic feet (untreated)	1	Risk factor for fungal infection or pitting keratolysis, community infective risk	Prescription-strength antiperspirant preparation, education re dietary restrictions (e.g. avoid chillies), podiatry treatment and patient education
Severe callus, corns or grossly thickened nails	14	Ulcer risk, (11 times more likely to ulcerate in diabetes)	Debridement, reduction, padding, offloading device or intervention, education of patient and medical personnel, footwear assessment, education
Skin and nail pathology (severe)	15	Ulcer risk (11 times more likely to ulcerate in diabetes)	Reduction, prevention of ulceration on IPJs, MPJs, plantar surface, patient education, footwear assessment and education
Total patients with dermal findings needing podiatric care/management/referral	63

Notes: Hx (history), Dx (diagnosis), DDx (differential diagnosis), Tx (treatment), DVT (deep vein thrombosis), PUVA (psoralen and ultraviolet A), Rx (prescription), IPJ (inter-phalangeal joint), MPJ (metatarsophalangeal joint).

Table 3: Cardiovascular findings by podiatrist, missing from diabetes clinic notes

Cardiovascular observations by podiatrist	n	“Red flag” relative importance	Suggested management, missing
Abnormal pulsatile waveforms on Doppler	1	Thrombus formation	ECG, bloods and medication review
Arrythmia or abnormal pulsatile waveforms	11	Thrombus formation	ECG, medication review
BPM < 40	2	Cardiac arrest	Evaluate if candidate for pacemaker, revise meds, admit to high care
Fem pop artery biphasic continuous (hot, painful knee but cold monophasic foot)	2	Fem pop thrombus/blockage	Refer for angiogram lower limb; re-vascularise
Medial arterial calcification ABPI reading > 1.4, Doppler waveform biphasic continuous	4	Strong predictor for future cardiovascular event	Refer for X-ray confirmation, supplementation vit K2, revise anticoagulant therapy, low-dose vit D, phosphate binders
Medial arterial calcification, severe	4	Strong predictor for future cardiovascular event	Refer for X-ray confirmation, supplementation vit K2, revise anticoagulant therapy? Low-dose vit D, phosphate binders?
Monophasic pedal pulses yet compression hose was dispensed for varicose leg pain at Embalenhle Clinic	1	Compression in presence of ischaemia can cause gangrene; ulcer risk	(Re-)education of clinic staff that only once Doppler ultrasound indicates good arterial supply can compression hose be dispensed. Refer to vascular for full Doppler exam
Pain in arms when lifting the arms	2	Rotator cuff disease or peripheral vascular disease; tendonitis, bursitis; nerve impingement	Investigation – orthopaedics, vascular, neurology
Pain in chest when lifting arms above shoulders	1	Thoracic outlet syndrome?	Investigation – cardiology
Pain on leg elevation	3	Peripheral arterial disease; nerve impingement	Investigation – vascular, neurology
Painful oedema of the feet	8	Indicator for cardiac failure; lymphoedema; renal disease; ulcer risk	Investigate low protein levels; medications (side effect?); venous insufficiency
Pedal pulses monophasic or biphasic continuous	10	High risk of non-healing pedal tissue, ulcer risk	Refer for angiogram lower limb; re-vascularise
Post-stroke	3	High fall risk	Refer to podiatrist re footwear, occupational therapy for devices
Weak bpm (Hx stroke)	1	Potential cardiac failure	Refer to cardiology, suitable patient for pacemaker?
Tachycardia (> 100 bpm resting)	7	If prolonged, syncope, cardiac failure, thrombus formation	Medication review (HBP), check electrolytes, cardiovascular workup?
Unilateral calf pain	5	Potential thrombus	Refer for angiogram lower limb; re-vascularise
Unilateral knee pain, hot to touch (leg wrapped with tight hose at the knee)	4	Potential thrombus	Refer for angiogram lower limb; re-vascularise
Total patients with cardiovascular findings needing podiatric care/management/referral	69

Notes: Hx (history), Dx (diagnosis), DDx (differential diagnosis), Tx (treatment).

Table 4: Musculoskeletal findings by podiatrist, missing from diabetes clinic notes

Musculoskeletal observations by podiatrist	n	“Red flag” relative importance	Suggested management, missing
Gait imbalance with leg pain	2	Unable to ambulate or exercise, fall risk, ulcer risk	Investigate musculoskeletal, biomechanics, gait function, vascular workup
Gait imbalance due to lumbar and unilateral leg pain	1	Fall risk, ulcer risk	Workup by podiatrist, imaging, in-shoe prescription insole
Mallet toes	1	Ulcer risk	Workup by podiatrist, conservative treatment with custom toe props to be fabricated in clinic from two-part silicone
Metatarsus adductus (uncorrected)	3	Callus formation due to shoe misfit, ulcer risk	Workup by podiatrist, templates by podiatrist for custom prescription shoe insert with components to be built in to support lateral borders of foot and prevent ulceration
Pain under the 1st MTPJ, Hx stumbled and fell	1	Ddx: plantar plate injury, sesamoiditis, bursitis, ischaemia, ulcer risk	Imaging investigation, workup by podiatrist, offloading in-shoe device made by podiatrist
Severe plantar fasciitis with suspected calcaneal spur	1	Inability to exercise, decreased blood supply, musculoskeletal compensatory fatigue, pain syndrome, inability to work	Refer for X-ray confirmation, send for in-shoe correction to be made by podiatrist, followed by physiotherapy once patient is pain-free
Shoes: high heels, biphasic pulses	2	Callus formation, decreased blood supply, ulcer risk	Workup by podiatrist, patient education, follow-up
Short first metatarsal (bilateral) with hallux rigidus, painful/symptomatic	38	Callus formation, musculoskeletal deformation (toes); ulcer risk	Workup by podiatrist, templates by podiatrist for custom prescription shoe insert with components built in to re-establish metatarsal parabolic action; patient education
Unilateral ankle pain	8	Unable to exercise, impacts vascular, impacts quality of life, ulcer risk	Imaging investigation, workup by podiatrist, offloading in-shoe device made by podiatrist
Unilateral knee imbalance	1	Unable to exercise, impacts vascular, impacts quality of life, ulcer risk	Imaging investigation, workup by podiatrist, offloading in-shoe device made by podiatrist
Unilateral short first metatarsal and back pain	1	Unable to exercise, impacts vascular, impacts quality of life, ulcer risk	In-shoe device for correction of gait imbalance
Total patients with musculoskeletal findings needing podiatric care/management/referral	59

Notes: Hx (history), Dx (diagnosis), DDx (differential diagnosis), MTPJ (metatarsophalangeal joint).

Table 5: Neural findings by podiatrist, missing from diabetes clinic notes

Neural observations by podiatrist	n	“Red flag” relative importance	Suggested management, missing
Gait anomaly Hx TB spine	1	Fall risk, ulcer risk	Supply crutches/walking aids, physiotherapy, podiatry in-shoe orthotics
Gait imbalance post-stroke (has no crutches or walking aid)	1	Fall risk, ulcer risk	Supply crutches/walking aids, physiotherapy, podiatry in-shoe orthotics, patient education
Hand paraesthesia as well as lower limb paraesthesia	1	Fall risk	Assess vit B12 levels, Rx medication for neuropathic pain, physiotherapy, occupational therapy
Ineffective pain medications given for neuropathic pain	1	Patient risks toxicity by self-medication dose increase	Pt had been given Tramadol, suggest rather carbamazepine or newer duloxetine
Pain in feet Hx meningitis with temporary paralysis	1	Fall risk due to painful gait, ulcer risk, loss of quality of life	Assess vit B12 levels, Rx medication for neuropathic pain, physiotherapy, podiatry
Retracted extensor tendons in presence of sensory neuropathy	3	High ulcer risk under MTPJs, DDx rhabdomyopathy	Neural support, e.g. vit B12, physiotherapy. Ulcer prevention for metatarsophalangeal joints, podiatry workup and podiatry orthotics
Shoe coring exposed (patient neuropathic and unaware)	1	Exposed holes can damage skin, ulcer risk	Patient education, clinic personnel education, podiatry offloading intervention
Shoes too small – patient unaware	3	Neuropathy causes patient to wear tighter shoes to increase diminishing sensation; ulcer risk	Patient education, clinic personnel education, podiatry foot protection intervention
Feet as cold as ice, not wearing socks	2	High ulcer risk, or burn risk	Refer for duplex Doppler, review medications, patient education, clinic personnel education
Total patients with neural findings needing podiatric care/management/referral	14

Notes: Hx (history), Dx (diagnosis), DDx (differential diagnosis), Tx (treatment), DVT (deep vein thrombosis), PUVA (psoralen and ultraviolet A), Rx (prescription), IPJ (inter-phalangeal joint), MTPJ (metatarsophalangeal joint).