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11/13/24, 7\:00 PM Guide | Diabetic foot examination

Diabetic foot examination

Table of contents
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0\:00 4\:22

Gather equipment

The following pieces of equipment may be required\:
Mono
Tuning fork (128 Hz)
Tendon hammer

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Adequately expose the patient's lower limbs.
Position the patient on the bed, with the head of the bed at 45°
.
Ask the patient if they have any pain before proceeding with the clinical examination.
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Inspection

Inspect the lower limbs for relevant pathology, making sure to look at the posterior aspect of each leg and between each of
the toes for hidden ulcers\:
Peripheral cyanosis\: bluish discolouration of the skin associated with low SpO 2
in the a
PVD due to poor perfusion).
Peripheral pallor\: a pale colour of the skin that can indicate poor perfusion.
Venous ulcers\: typically large and shallow ulcers with irregular borders that are only mildly painful. These ulcers most
commonly develop over the medial aspect of the ankle.
Arterial ulcers\: typically small, well-de
most peripheral regions of a limb (e.g. the ends of digits).
Gangrene\: tissue necrosis secondary to inadequate perfusion. Typical appearances include a change in skin colour (e.g. red,
black) and breakdown of the associated tissue.
Missing limbs, toes,
Scars\: may indicate previous surgical procedures (e.g. bypass surgery) or healed ulcers.
Hair loss\: occurs due to chronic impairment of tissue perfusion in PVD.
Foot calluses\: often caused by an abnormal gait and/or poorly
Venous guttering\: veins that have very little blood within them due to poor blood supply to the limb, hence the "guttered"
appearance
Charcot arthropathy
Charcot arthropathy involves the progressive degeneration of a weight-bearing joint due to peripheral neuropathy.
The typical clinical features of a Charcot's joint include\:
E
Distortion
Overlying erythema
Loss of joint function
Inspect the lower limbs for skin changes associated with peripheral vascular disease
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Palpation

Temperature

Place the dorsal aspect of your hand onto the patient’s lower limbs to assess and compare temperature\:
In healthy individuals, the lower limbs should be symmetrically warm, suggesting adequate perfusion.
A cool and pale limb is indicative of poor arterial perfusion.

Pulses

Palpate the posterior tibial and dorsalis pedis pulse to brie
suggestive of peripheral vascular disease.
Posterior tibial pulse
Palpate the posterior tibial pulse\:
The posterior tibial pulse can be located posterior to the medial malleolus of the tibia.
Palpate the pulse to con
Dorsalis pedis pulse
Palpate the dorsalis pedis pulse\:
The dorsalis pedis pulse can be located over the dorsum of the foot, lateral to the extensor hallucis longus tendon, over
the second and third cuneiform bones.
Palpate the pulse to con
Assess and compare leg temperature

Sensation

Mono

1. Provide an example of the mono
2. With the patient's eyes closed, apply the mono
The pulp of the hallux.
The pulp of the third digit.
Metatarsophalangeal joints 1, 3 and 5.
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3. When applying the mono
Ask the patient to report when they feel the mono
Press the mono
Hold the mono
Avoid calluses and scars as they have a reduced level of sensation that is not representative of the surrounding tissue.
Provide an example of the mono

Gait

Peripheral neuropathy associated with diabetic foot disease can result in the development of an abnormal gait. Patients with
peripheral neuropathy may demonstrate a conservative gait strategy in which their walking speed is reduced and their foot
stance is broadened. The development of foot drop is also more common in diabetic patients, which can result in a high-
stepping gait.

Assess the patient's gait

Patients with diabetic foot disease are often at an increased risk of falls so make sure to remain close to the patient during the
assessment so that you are able to intervene if required.
Ask the patient to walk to the end of the examination room and then turn and walk back whilst you observe their gait paying
attention to\:
Speed\: gait speed may be reduced signi
Stance\: a broad-based gait may be associated with advanced peripheral neuropathy to increase stability.
Steps\: high-stepping may indicate the presence of foot drop.
Turning\: patients with peripheral neuropathy can
to impairment of sensation and proprioception.

Examine the patient's footwear

The use of appropriate footwear is particularly important for diabetic patients due to the presence of impaired sensation and
poor peripheral perfusion. Inappropriately
and the formation of a diabetic foot ulcer.
Inspect the patient's footwear\:
Note the pattern of wear on the soles (asymmetrical wearing may indicate an abnormal gait).
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Check that the shoes are the correct size for the patient.
Ensure there are no materials within the shoe that could cause foot injury.
Observe the patient's gait

Other assessments to consider

If abnormalities are identi
shown below (these are no longer performed routinely in a diabetic foot assessment).

Vibration sensation

Vibration sensation involves the dorsal columns.
1. Ask the patient to close their eyes and to let you know both when they can detect vibration and when it stops.
2. Tap a 128 Hz tuning fork and place onto the patient's sternum to check they are able to feel it vibrating. Then grasp the ends
of the tuning fork to cease vibration and see if the patient is able to accurately identify that it has stopped.
3. Tap the tuning fork again and place onto the interphalangeal joint of the patient's big toe. If the patient is able to accurately
identify when the vibration begins and when it stops at this point in both lower limbs, the assessment is complete.
4. If vibration sensation is impaired at the interphalangeal joint of the patient's big toe, continue to sequentially assess more
proximal joints (e.g. metatarsophalangeal joint of the big toe → ankle joint → knee joint) until the patient is able to accurately
identify vibration.
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Provide an example of vibration sensation

Proprioception

Proprioception, also known as joint position sense, involves the dorsal columns.
1. Begin assessment of proprioception at the interphalangeal joint of the big toe by holding the distal phalanx of the big toe by
its sides (avoid holding the nail bed as this can allow the patient to determine direction based on pressure).
2. Demonstrate movement of the big toe "
upwards" and "downwards" to the patient whilst they watch.
3. Ask the patient to close their eyes and state if you are moving their big toe up or down.
4. Move the big toe up or down 3-4 times in a random sequence to see if the patient is able to accurately identify joint position
with their eyes closed.
5. If the patient is unable to correctly identify the direction of movement, continue to sequentially assess more proximal joints
(e.g. metatarsophalangeal joint of the big toe → ankle joint → knee joint).
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Hold the distal phalanx of the great toe by its sides

Ankle-jerk re

Assess the ankle-jerk re
There are several methods for eliciting the ankle-jerk re
The ankle jerk re
Method 1
ankle is dorsi
1. With the patient on the examination couch support their leg so that their hip is slightly abducted, the knee is
2. Tap the Achille's tendon with the tendon hammer and observe for a contraction in the gastrocnemius muscle with associated
plantar
Method 2
1. Ask the patient to kneel on a chair and hold the back of it to steady themselves.
2. Tap the Achille's tendon with the tendon hammer and observe for a contraction in the gastrocnemius muscle with associated
plantar
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Assess the ankle jerk re

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your
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