Diabetic Foot Examination
Foot ulcers and other peripheral diabetic complications are common, and associated with high levels of morbidity and mortality. Early detection and preventative management leads to fewer lower limb amputations.
- Introductions, explanation and consent
- Wash hands
- Perfusion- pale, or pink and well perfused?
- Any areas of discolouration
Appearance of skin
- Hair loss
- Dry or moist?
- Shiny (indicating oedema)
- Calluses & hypertrophic skin (precursor to ulcers)
- Venous- moderate to large size, no pain
- Arterial- deep, well demarcated, very painful
- Fungal or ingrown nails
- Look all over the foot and ankle
- Look between the toes- deeper lesions may be missed!
- Look under the heel
- Temperature of foot
- Symmetry of temperature
- Dorsalis Pedis
- Posterior Tibialis
Patients with neurological loss of protective sensation (LOPS) are at increased risk of unrecognised injury, leading to ulceration and additional complications.
During all sensory assessments, first display what your sensation will feel like on the sternum, then ask the patient to close their eyes and tell you when they can feel it and if it feels the same on both sides.
- Microfilament (don't use a neurotip - may cause break in skin that leads to ulceration)
- Press the monofilament firmly so that the tip bends, for 1-2 seconds.
- If a discrepancy is found then perform a sensory level test, i.e. keep touching up the leg until the patient can feel it
- Test on the sole; big toe (L4), little toe (L5), heel (S1)
Place a 128 Hz tuning fork on the first joint of the big toe
- Best predictor of long-term vascular complications
Ipswich Touch Test
- Rest your index finger lightly on the patients first, third, and fifth toes
- As accurate at detecting LOPS as a monofilament test
Observe for deformity e.g. hammer toe, claw toe, charcot neuropathy
Inspect the patient's shoes for unusual wear patterns
- Foot drop or dragging of feet
- Ankle jerk (S1,2)
- This is less well researched in diabetic foot care, and does not feature in evidence-based assessments, however it is still often performed in the clinical setting.
- Start at the first joint of the big toe, show them what you mean by up and down and then get them to close their eyes and get them to tell you which way you are moving their toe.
- Remember to hold the toe at the sides and isolate the joint.
- Boulton AJ, Armstrong DG, Albert SF, et al; American Diabetes Association; American Association of Clinical Endocrinologists. Comprehensive foot examination and risk assessment: a report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care. 2008;31:1679-1685.
- Shearer A, Scuffham P, Gordois A, et al. Predicted costs and outcomes from reduced vibration detection in people with diabetes in the U.S. Diabetes Care. 2003;26:2305-2310.
- Rayman G, Vas PR, Baker N, et al. The Ipswich Touch Test: a simple and novel method to identify inpatients with diabetes at risk of foot ulceration.Diabetes Care. 2011;34:1517-1518.
- Boulton AJM, Armstrong DG, Albert SF, et al. Comprehensive Foot Examination and Risk Assessment: A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists . Diabetes Care. 2008;31(8):1679-1685. doi:10.2337/dc08-9021. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2494620/