Osteopathic Approach to Diabetic Foot Care

• Osteopathic approach to diabetic foot care integrates 5 models of osteopathic care and the four tenets for managing diabetic patients.
• It formulates differential diagnoses utilizing the 5 osteopathic models.
• It describes the adaptive responses of the lower extremity, pelvis, and lumbar spine to diabetic foot changes.
• It identifies the grading system for diabetic foot ulcers.

Learning Objectives

• Describe how to manage those patients incorporating 5 models of osteopathic care and the four tenets.
• Formulate a differential diagnosis for said patient using the 5 models of osteopathic care.
• Describe possible adaptive responses of the lower extremity, pelvis, and lumbar spine in response to changes in the diabetic foot.
• Identify the grading system for diabetic foot ulcers.
• Create a patient care plan utilizing the 5 models of osteopathic care.
• Identify labs, imaging, and other tests to evaluate the patient's suspected diagnosis and interpret the results correctly.
• Apply knowledge of anatomy, physiology, and pathophysiology to identify and apply appropriate osteopathic manipulative techniques for somatic dysfunction and to facilitate restoration of health.
• Correctly perform OMT to somatic dysfunction related to diabetes and diabetic foot conditions.
• Apply scientific literature evidence to guide the safe and effective use of OMT for patients with this condition.

SOAP Note: Patient History

• A 55-year-old woman with a history of type II diabetes presents with right foot pain.
• The patient describes the pain as a constant throbbing, rated 5/10, and located on the bottom of the right forefoot, exacerbated by walking.
• Swelling and increasing brownish-yellow drainage are noted in the affected area.
• Acetaminophen provided minimal pain relief, and pain worsens with pressure.
• The patient reports decreased foot range of motion, bilateral lower extremity edema, and intermittent numbness/tingling in both feet for several months.
• The patient denies fever, muscle weakness, or trauma.
• The patient admits to non-compliance with diabetic medication and not wearing shoes at home.
• Allergies: NKA (no known allergies)
• Medications: Metformin 850mg PO bid (non-adherent), Calcium + Vitamin D supplement OTC qd
• PMHx: Type II diabetes mellitus x 5 years and history of gastroparesis x 2 years
• PSHx: None
• FHx: Mother with type II diabetes, father died of stroke at 70, and a sister and brother with unknown health status
• SocHx: Married with five children, housewife, rarely exercises, and denies tobacco, alcohol, or drug use.

Review of Systems (ROS)

• GEN: 10 lb weight gain since last visit 1 year ago, + fatigue
• HEENT: + blurry vision, + difficulty reading, no ophthalmologist despite referral
• CARDIO: denies chest pain or palpitations
• RESP: denies shortness of breath or cough
• GI: + intermittent constipation, nausea, early satiety with abdominal pain, denies vomiting and diarrhea
• NEURO: + occasional numbness and tingling in lower extremities bilaterally
• ENDO: + nocturia, + polyuria, denies temperature hypersensitivity, changes in hair/nails

Physical Examination

• Vitals: Weight 165lbs, Height 5'2", BMI 30.2, HR 75, RR 19, BP 135/75, T98.6F, Pain 5/10
• GEN: Obese female in no apparent distress
• CV: RRR, no rubs/gallops/clicks/murmurs, Pulses 2/4 in bilateral radial artery, 1/4 in bilateral dorsalis pedis and posterior tibial arteries, Capillary refill <2s in bilateral UE and sluggish in bilateral LE, No carotid bruits
• PULM: CTAB, No wheezes, rales, rhonchi
• GI: Obese body habitus, Decreased bowel sounds in all four quadrants, no bruits, no hepatosplenomegaly, no masses, mild epigastric tenderness with slight distention, no guarding or rigidity
• NEURO: A&O x 4, CN II-XII grossly intact bilaterally, Bilateral feet: sensation - decreased soft touch sensation, and sensation to pinprick, decreased sensation to 10-gram Semmes-Weinstein monofilament, decreased vibration sense bilaterally.
• DERM: No acanthosis nigricans noted, A 1.5cm-diameter circular, pink-purple area of discoloration with skin breakdown 2mm in depth with no tendon or bone exposed is present on the plantar foot around the right second metatarsal head, Serosanguinous discharge noted, The lesion base is granular with surrounding edema, erythema, and warmth.

MSK/OSTEOPATHIC Findings

• CERVICALS: bogginess in posterior cervical spine bilaterally
• THORACICS: Dry, ropy, and cool to the touch at T7-9 bilaterally, Also found at T11-L2 on the right
• ABDOMEN: B/L diaphragm restriction
• PELVIS: +L seated flexion test, deep sacral sulcus on the left, posterior ILA on the right, backward bending test symmetrical, negative spring test, L5 NRLSR. +R standing flexion test, R ASIS superior, R PSIS inferior, R pubic bone superior. Negative inflare/outflare.
• LE:
  • Swelling limited to below the knee bilaterally.
  • Externally rotated R tibia, anterior R fibular head
  • Right foot with decreased active and passive range of motion in all directions.
  • Right foot tenderpoints at cuboid counterstrain point (7/10) and navicular counterstrain point (5/10).
  • Bilateral inverted navicular and everted cuboid.

Differential Diagnoses for Right Foot Pain in Uncontrolled Diabetes

Respiratory/Circulatory:

• Avascular necrosis
• Vasculopathy
• Thrombosis

Biomechanical:

• Trauma
• Fracture
• Charcot joint

Neurological:

• Diabetic neuropathy
• Radiculopathy

Metabolic:

• Gout
• Cancer
• Infection

Biopsychosocial:

• Depression
• Poor footwear/hygiene
• Malingering
• Remember overlap can occur within the 5 models.

Labs

• Random blood glucose: 285 mg/dL
• HbA1c: 11.5% (poor glycemic control)
• Elevated WBC: 12,500 per µL (4,500-11,000 per µL is reference range)

Assessment

Working Diagnosis

• Diabetic foot ulcer, Grade 1 (E11.621)

Chronic Diagnoses

• Type 2 Diabetes Mellitus with Diabetic Neuropathy (E11.40), non-compliant
• Obesity (E66.9)
• Gastroparesis due to Type 2 Diabetes Mellitus (E11.43) (K31.84)

Lifestyle

• Sedentary lifestyle

OMM Diagnosis

• SD of cervicals (M99.01), thoracics (M99.02), lumbars (M99.03), pelvis (M99.05), sacrum (M99.04) & lower extremity (M99.06)

Explore the osteopathic approach to diabetic foot care through five models and four tenets. Learn differential diagnosis using osteopathic models. Understand lower extremity, pelvis, and lumbar spine responses to diabetic foot changes. Identify the diabetic foot ulcer grading system.