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
- Pallor – indicates 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
- 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
- Using 10g monofilament testing
Move
- Examine the range of movement – reduced in Charcot foot
- Gait assessment can show this grossly
Follow up
- Full Arterial exam of lower limb
- Ischaemic changes
- Pulses
- ABPI examination
- Full Neurological exam of lower limb
- Investigations
- CBG
- May do NCS if unsure of the cause of neuropathy
- Doppler if unable to palpate pulses