Diabetic Foot Examination

This shares a lot of elements with both the arterial exam and neurological exam of the lower limb

Setting up
  • Wash Hands
  • Introduce
  • Permission
  • Ask about pain
  • Expose the foot
Look

The inspection includes aspects of the arterial and neuro lower limb exams

  • Any obvious deformities – e.g. charcot arthropathy
  • Pallorindicates arterial pathology
  • Skin changes  dryness, hair loss, shiny
  • Calluses indicate poor-fitting shoes and potential underlying infection
  • Ulcers check the plantar surface, back and between toes
    • Arterial – painful, pale, no blood flow, on periphery
    • Neurological – painless, perfused, on pressure points
    • (Venous – gaiter region, poorly circumscribed)
    • Most patients will have a neuroarteriopathic picture in diabetic foot
  • Also inspect the patient’s shoes for signs of abnormality and whether they are well-cushioned
Feel
  • Temperature down the legs
  • Capillary refill  prolonged in arterial disease
  • Foot pulses – dorsalis pedis and post. Tibial
    • Move up to popliteal
    • Will be lost in arteriopathic patients
  • Examine sensation – there are 2 aspects to this
    • Using 10g monofilament testing
      • Put the monofilament on the patients sternum to explain the feeling
      • Press filament firmly against the skin for 1-2 seconds – filament will bend
      • Close patient’s eyes and place monofilament in several pressure points
        • 5 Metatarsal heads
        • Big toe and middle toe
        • Heel and midfoot sole
        • Dorsum of foot
    1. Vibration sense
      • Use a 128Hz and place it on the distal phalanx
      • Reduced in neuropathy
    • Other tests including proprioception and ankle jerk might be used if vibration or monofilament is abnormal
Move
  • Examine the range of movementreduced in Charcot foot
    • Gait assessment can show this grossly

Follow up 

  1. Full Arterial exam of lower limb
    • Ischaemic changes
    • Pulses
    • ABPI examination
  2. Full Neurological exam of lower limb
  3. Investigations
    • CBG
    • May do NCS if unsure of the cause of neuropathy
    • Doppler if unable to palpate pulses