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Comprehensive Foot Examination and Risk Assessment

foot exam

Diabetes Foot Exam

One in four people with diabetes will develop foot problems that require treatment.

You can develop different types of foot problems, but all can lead to serious complications if left untreated. Diabetes can damage the nerves in your feet, causing you to lose your ability to feel pain or discomfort. This is called diabetic neuropathy. Diabetes can also cause circulation problems, which can prevent you from healing as quickly as people without diabetes do.

The Clinical Guidelines recommend that you have your feet checked at least annually for altered sensation, decreased circulation and/or infection.

There are several parts of a foot exam. First, the doctor performs a visual inspection, looking for skin color changes, cuts and other damage. The doctor will then take a look between your toes, because often infections can start there. The doctor will also take a pulse at key points of the foot to determine the level of circulation. There will also be a test of sensation, where the doctor may use a tuning fork, a pin wheel or a tool called a tin gram fiber to evaluate your awareness of touch, dull versus sharp pain, movement of the tool across the skin and so on.

If you already have diabetic neuropathy, you need to inspect your feet daily and look for cuts, blisters, sores, signs of infection or changes in color or temperature. People who have neuropathy are more likely to have the more significant foot complications.

Smoking has a huge impact on the likelihood of people with diabetes developing foot complications because it affects the circulation and causes nerve damage. So if you still light up, please stop as soon as possible.

So what else can you do to protect your feet? We have already talked about smoking and the need to stop. Have regular foot exams and if you have diabetic neuropathy check your feet daily.


Components of the foot exam

While history is a pivotal component of risk assessment, a patient cannot be fully assessed for risk factors for foot ulceration based on history alone; a careful foot exam remains the key component of this process. Key components of the history include previous foot ulceration or amputation. Other important assessments in the history include neuropathic or peripheral vascular symptoms, impaired vision, or renal replacement therapy. Lastly, tobacco use should be recorded, since cigarette smoking is a risk factor not only for vascular disease but also for neuropathy.


Risk factors for foot ulcers

  • Previous amputation
  • Past foot ulcer history
  • Peripheral neuropathy
  • Foot deformity
  • Peripheral vascular disease
  • Visual impairment
  • Diabetic nephropathy (especially patients on dialysis)
  • Poor glycemic control
  • Cigarette smoking

Essential features of history

Past history

  • ulceration
  • amputation
  • Charcot joint
  • vascular surgery
  • angioplasty
  • cigarette smoking

Neuropathic symptoms

  • positive (e.g., burning or shooting pain, electrical or sharp sensations, etc.)
  • negative (e.g., numbness, feet feel dead)

Vascular symptoms

  • claudication
  • rest pain
  • nonhealing ulcer

Other diabetes complications

  • renal (dialysis, transplant)
  • retinal (visual impairment)

General inspection

A careful inspection of the feet in a well-lit room should always be carried out after the patient has removed shoes and socks. Because inappropriate footwear and foot deformities are common contributory factors in the development of foot ulceration, the shoes should be inspected and the question “Are these shoes appropriate for these feet?” should be asked. Examples of inappropriate shoes include those that are excessively worn or are too small for the person's feet (too narrow, too short, toe box too low), resulting in rubbing, erythema, blister, or callus. Features that should be assessed during foot inspection are outlined in discussed below.

Key components of the diabetic foot exam


  • skin status: color, thickness, dryness, cracking
  • sweating
  • infection: check between toes for fungal infection
  • ulceration
  • calluses/blistering: hemorrhage into callus?


  • deformity, e.g., claw toes, prominent metatarsal heads, Charcot joint
  • muscle wasting (guttering between metatarsals)

Neurological assessment

10-g monofilament + 1 of the following 4

  • vibration using 128-Hz tuning fork
  • pinprick sensation
  • ankle reflexes
  • VPT

Neurological assessment

  • foot pulses
  • ABI, if indicated

Dermatological assessment.

The dermatological assessment should initially include a global inspection, including interdigitally, for the presence of ulceration or areas of abnormal erythema. The presence of callus (particularly with hemorrhage), nail dystrophy, or paronychia should be recorded (9), with any of these findings prompting referral to a specialist or specialty clinic. Focal or global skin temperature differences between one foot and the other may be predictive of either vascular disease or ulceration and could also prompt referral for specialty foot care (10–13).

Musculoskeletal assessment.

The musculoskeletal assessment should include evaluation for any gross deformity (14). Rigid deformities are defined as any contractures that cannot easily be manually reduced and are most frequently found in the digits. Common forefoot deformities that are known to increase plantar pressures and are associated with skin breakdown include metatarsal phalangeal joint hyperextension with interphalangeal flexion (claw toe) or distal phalangeal extension.

An important and often overlooked or misdiagnosed condition is Charcot arthropathy. This occurs in the neuropathic foot and most often affects the midfoot. This may present as a unilateral red, hot, swollen, flat foot with profound deformity (18–20). A patient with suspected Charcot arthropathy should be immediately referred to a specialist for further assessment and care.

Neurological assessment

Peripheral neuropathy is the most common component cause in the pathway to diabetic foot ulceration. The clinical exam recommended, however, is designed to identify loss of protective sensation (LOPS) rather than early neuropathy. The diagnosis and management of the latter were covered in a 2004 ADA technical review. The clinical examination to identify LOPS is simple and requires no expensive equipment.

Five simple clinical tests, each with evidence from well-conducted prospective clinical cohort studies, are considered useful in the diagnosis of LOPS in the diabetic foot. The task force agrees that any of the five tests listed could be used by clinicians to identify LOPS, although ideally two of these should be regularly performed during the screening exam—normally the 10-g monofilament and one other test. One or more abnormal tests would suggest LOPS, while at least two normal tests (and no abnormal test) would rule out LOPS. The last test listed, vibration assessment using a biothesiometer or similar instrument, is widely used in the U.S.; however, identification of the patient with LOPS can easily be carried out without this or other expensive equipment.

10-g monofilaments.

Monofilaments, sometimes known as Semmes-Weinstein monofilaments, were originally used to diagnose sensory loss in leprosy. Many prospective studies have confirmed that loss of pressure sensation using the 10-g monofilament is highly predictive of subsequent ulceration . Screening for sensory loss with the 10-g monofilament is in widespread use across the world, and its efficacy in this regard has been confirmed in a number of trials, including the recent Seattle Diabetic Foot Study.

Nylon monofilaments are constructed to buckle when a 10-g force is applied; loss of the ability to detect this pressure at one or more anatomic sites on the plantar surface of the foot has been associated with loss of large-fiber nerve function. It is recommended that four sites (1st, 3rd, and 5th metatarsal heads and plantar surface of distal hallux) be tested on each foot.

The technique for testing pressure perception with the 10-g monofilament is illustrated patients should close their eyes while being tested. Caution is necessary when selecting the brand of monofilament to use, as many commercially available monofilaments have been shown to be inaccurate. Single-use disposable monofilaments or those shown to be accurate by the Booth and Young study are recommended. The sensation of pressure using the buckling 10-g monofilament should first be demonstrated to the patient on a proximal site (e.g., upper arm). The sites of the foot may then be examined by asking the patient to respond “yes” or “no” when asked whether the monofilament is being applied to the particular site; the patient should recognize the perception of pressure as well as identify the correct site. Areas of callus should always be avoided when testing for pressure perception.

128-Hz tuning forks.

The tuning fork is widely used in clinical practice and provides an easy and inexpensive test of vibratory sensation. Vibratory sensation should be tested over the tip of the great toe bilaterally. An abnormal response can be defined as when the patient loses vibratory sensation and the examiner still perceives it while holding the fork on the tip of the toe.

Pinprick sensation.

Similarly, the inability of a subject to perceive pinprick sensation has been associated with an increased risk of ulceration. A disposable pin should be applied just proximal to the toenail on the dorsal surface of the hallux, with just enough pressure to deform the skin. Inability to perceive pinprick over either hallux would be regarded as an abnormal test result.

Ankle reflexes.

Absence of ankle reflexes has also been associated with increased risk of foot ulceration. Ankle reflexes can be tested with the patient either kneeling or resting on a couch/table. The Achilles tendon should be stretched until the ankle is in a neutral position before striking it with the tendon hammer. If a response is initially absent, the patient can be asked to hook fingers together and pull, with the ankle reflexes then retested with reinforcement. Total absence of ankle reflex either at rest or upon reinforcement is regarded as an abnormal result.

Vibration perception threshold testing.

The biothesiometer (or neurothesiometer) is a simple handheld device that gives semiquantitative assessment of vibration perception threshold (VPT). As for vibration using the 128-Hz tuning fork, vibration perception using the biothesiometer is also tested over the pulp of the hallux. With the patient lying supine, the stylus of the instrument is placed over the dorsal hallux and the amplitude is increased until the patient can detect the vibration; the resulting number is known as the VPT. This process should initially be demonstrated on a proximal site, and then the mean of three readings is taken over each hallux. A VPT >25 V is regarded as abnormal and has been shown to be strongly predictive of subsequent foot ulceration.

Vascular assessment

Peripheral arterial disease (PAD) is a component cause in approximately one-third of foot ulcers and is often a significant risk factor associated with recurrent wounds. Therefore, the assessment of PAD is important in defining overall lower-extremity risk status. Vascular examination should include palpation of the posterior tibial and dorsalis pedis pulses, which should be characterized as either “present” or “absent”.

Diabetic patients with signs or symptoms of vascular disease or absent pulses on screening foot examination should undergo ankle brachial pressure index (ABI) pressure testing and be considered for a possible referral to a vascular specialist. The ABI is a simple and easily reproducible method of diagnosing vascular insufficiency in the lower limbs. Blood pressure at the ankle (dorsalis pedis or posterior tibial arteries) is measured using a standard Doppler ultrasonic probe. This technique is outlined. The ABI is obtained by dividing the ankle systolic pressure by the higher of the two brachial systolic pressures. An ABI >0.9 is normal, <0.8 is associated with claudication, and <0.4 is commonly associated with ischemic rest pain and tissue necrosis.

The ADA Consensus Panel on PAD recommended measurement of ABI in diabetic patients over 50 years of age and consideration of ABI measurement in younger patients with multiple PAD risk factors, repeating normal tests every 5 years. ABI may therefore be part of the annual comprehensive foot exam in these patient subgroups. ABI measurements may be misleading in diabetes because the presence of medial calcinosis renders the arteries incompressible and results in falsely elevated or supra-systolic ankle pressures. In the presence of incompressible calf or ankle arteries (ABI >1.3), measurements of digital arterial systolic pressure (toe pressure) or transcutaneous oxygen tension may be performed.

Risk classification and referral/follow-up

Once the patient has been thoroughly assessed as described above, he or she should be assigned to a foot risk category. These categories are designed to direct referral and subsequent therapy by the specialty clinician or team and frequency of follow-up by the generalist or specialist. Increased category is associated with an increased risk for ulceration, hospitalization, and amputation. Patients in risk category 0 generally do not need referral and should receive general foot care education and undergo comprehensive foot examination annually. Patients in foot risk category 1 may be managed by a generalist or specialist every 3–6 months. Consideration should be given to an initial specialist referral to assess the need for specialized treatment and follow-up. Those in categories 2 and 3 should be referred to a foot care specialist or specialty clinic and seen every 1–3 months.

Risk classification based on the comprehensive foot examination

Risk category Definition Treatment recommendations Suggested follow-up
0 No LOPS, no PAD, no deformity Patient education including advice on appropriate footwear. Annually (by generalist and/or specialist)
1 LOPS ± deformity 1. Consider prescriptive or accommodative footwear.
2. Consider prophylactic surgery if deformity is not able to be safely accommodated in shoes. Continue patient education.
Every 3–6 months (by generalist or specialist)
2 PAD ± LOPS 1. Consider prescriptive or accommodative footwear.
2.Consider vascular consultation for combined follow-up.
Every 2–3 months (by specialist)
3 History of ulcer or amputation 1. Same as category 1.
2. Consider vascular consultation for combined follow-up if PAD present.
Every 1–2 months (by specialist)


It cannot be overstated that the complications of the diabetic foot are common, complex, and costly, mandating aggressive and proactive preventative assessments by generalists and specialists. All patients with diabetes must have their feet evaluated at least at yearly intervals for the presence of the predisposing factors for ulceration and amputation (neuropathy, vascular disease, and deformities). This report summarizes a simple protocol for doing so. If abnormalities are present, more frequent evaluation of the diabetic foot is recommended depending on risk category, as described above and in Table 4. It is through systematic examination and risk assessment, patient education, and timely referral that we may further reduce the unnecessarily high prevalence of lower-extremity morbidity in this population.

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