Diabetic foot
> examination


  • Home
  • Trauma
    • Pilon fractures
    • Ankle fractures
    • Talus fractures
    • Calcaneal fractures
    • Lisfranc injuries
    • 5th metatarsal fractures
    • Achilles tendon rupture
  • General
    • Diabetic foot
    • Rheumatoid foot
    • Pes cavus
    • Flatfoot (general)
  • Ankle
    • Instability
    • Impingement
    • Osteochondral lesions
    • Osteoarthritis
  • Hind/midfoot
    • Tarsal joint problems
    • Heel pain/plantar fasciitis
    • Tarsal tunnel syndrome
    • Sinus tarsi syndrome
    • Ganglia
  • Tendons
    • Achilles tendonopathy
    • Tibialis posterior tendonopathy/adult acquired flatfoot
    • Peroneal tendon problems
  • First ray
    • Hallux valgus
    • Hallux rigidus
    • Hallux varus
    • Sesamoid problems
    • Ingrowing toenail
    • Subungual exostosis
  • Lesser rays
    • Lesser toe problems
    • Metatarsalgia
    • Metatarsophalangeal instability
    • Interdigital neuroma
    • Freiberg's disease
    • Bunionette
  • quickGuides
    • Heel pain
    • Hallux valgus

Diabetic foot

  • introduction
  • pathology
    • ulcers
    • Charcot
  • classification
    • ulcers
    • Charcot
  • epidemiology
  • clinical assessment
    • history
    • examination (this page)
    • risk assessment
  • investigation
  • management
    • prevention
    • simple ulcers
    • ulcers + infection
    • early Charcot
    • late Charcot deformities

Last evidence check April 2008

Examination

If the patient has presented with a non-diabetic primary problem eg hallux valgus, this should be assessed in the normal way.

A general physical examination should be carrid out as indicated, bearing in mind the likelihood that a diabetic patient is more likely to have cardiac, vascular, renal or eye disease and that any of these may, at least, affect their fitness for surgery.

Testing pressure sensation with the 10g Semmes-Weinstein filament. First demonstrate on your own hand to show the filament is not sharp and will not be painful. Check the patient can feel the filament on their own hand (if they can't, use the forehead). Ask them to close their eyes and tell you when they feel pressure, and to tell you where they feel it. Press the filament against multiple sites on toes and foot until it bends. Failure to feel the filament at one site is usually considered a positive test for neuropathy, although some groups use more stringent criteria which increase specificity at the expense of sensitivity

Neuropathy

The diagnosis of peripheral neuropathy is perhaps the most important specialised part of the physical examination in the diabetic. A neuropathic foot is typically warm and dry with bounding pulses. Light touch, pain, temperature, vibration and proprioception should be tested. Several instruments and devices have been described. The simplest and most widely used is the Semmes-Weinstein neurofilament. Originally described for sensory testing in leprosy, these are flexible filaments of varying thicknesses which bend when applied to the skin with specific loads. The most commonly used bends at a load of 10g, but other thicknesses are available. It should be applied at several sites at the tips of the toes, under the metatarsal heads and heel and otherwise as indicated. Saltzmann (2005) found that testing with the 4.5g filament under the first metatarsal head was as sensitive as the 10g filament applied to multiple sites, while Kamei (2005) found the 2g filament more sensitive. Kamei also found the 125Hz tuning fork applied to the apex of the hallux more sensitive than the 10g filament. Another device uses the ability to distinguish between one and two points of pressure and is also reported as more accurate than the 10g filament. Although the 10g filament is very portable and convenient, it may be superseded by other techniques.

doppler

Measuring pedal arterial pressures with a Doppler probe

Vascular disease

Vascular disease should be assessed by examination of the skin quality and palpation of the peripheral pulses. Auscultate the femoral artery for bruits. A Doppler probe can be used to help measure the pressures in the pedal vessels, but if the vessels are sclerotic or calcified, as many diabetics' are, they may not be compressible enough to do the test. Alternatively, toe pressure cuffs can be used. Transcutaneous oxygen saturation measurement is reasonably predictive of wound healing, but very technique-dependent.

ulcer

A large, deep ulcer under the 2nd and 3rd MT heads, after removal of callus and slough

Ulcers

The size and depth of any ulcer should be measured. A sterile probe can be used to assess the base of the ulcer - if the probe reaches bone it is likely that osteomyelitis is present. Most fresh ulcers are surrounded by extensive callus. This should be removed, both for therapy and full assessment of the ulcer.

Deformities

Deformities should be noted and examined to determine how correctable they are. Stiff deformities increase diabetic foot pressures markedly and contribute significantly to ulcer risk. Look, in particular, for:

  • Achilles/gastrocnemius tightness
  • flatfoot or cavus
  • midfoot or hindfoot deformities secondary to previous Charcot arthropathy
  • hallux valgus
  • lesser toe deformities