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Diabetic Foot Examination

From Mediwikis

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

Dermatological Assessment

Colour

  • 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[1])
  • Eczema

Ulcers

  • Venous- moderate to large size, no pain
  • Arterial- deep, well demarcated, very painful

Toes

  • Fungal or ingrown nails

Review areas

Arterial ulcer peripheral vascular disease
  • Look all over the foot and ankle
  • Look between the toes- deeper lesions may be missed!
  • Look under the heel

Vascular Assessment

  • Temperature of foot
    • Symmetry of temperature
  • Pulses
    • Dorsalis Pedis
    • Posterior Tibialis
    • Popliteal
    • Femoral

Neurological Assessment

Patients with neurological loss of protective sensation (LOPS) are at increased risk of unrecognised injury, leading to ulceration and additional complications.

Sensation

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.

Fine touch

  • 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)

Vibration

Place a 128 Hz tuning fork on the first joint of the big toe

  • Best predictor of long-term vascular complications[2]

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[3]

Neuromuscular Assessment

Charcot arthropathy

Observe for deformity e.g. hammer toe, claw toe, charcot neuropathy

Inspect the patient's shoes for unusual wear patterns

Inspect gait

Looking for:

  • Symmetry
  • Balance
  • Foot drop or dragging of feet

To finish

  • Reflexes
    • Ankle jerk (S1,2)
  • Proprioception
    • 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.[4]
    • 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.

References

  1. 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.
  2. 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.
  3. 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.
  4. 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/