Diabetic foot examination

Question 1

Components of diabetic foot examination?

Answer 1

1. General inspection - missing limbs or toes, limb palor, limb erythema, walking aids?
2. Inspect leg for: Hair loss, skin changes (dry or erythema), ulcers, joint deformity
3. Inspect feet - between toes for hidden ulcers and also heels CHECK BOTTOM OF FEET - injury, bad footwear, gait abnormalities
4. Assess or compare leg temperature - DVT/Cellulitis
5. Cap refil in toes
6. Assess pulses (dorsalis pedis, posterior tibial)
7. Monofilament testing - demonstrate on arm first (apply enough pressure for monofilament to bend) - asses below EACH TOE and also the big toe itself.
8. Vibration testing on distal bony prominence (demonstrate on sternum first for ref)
9. Propioception/reflexes (ankle jerk) if abnormlaities
10. Gait
11. Inspect shoes for evenness of sole wear

Question 2

What might an antalgic gait in a diabetic foot examination suggest?

Answer 2

Joint trauma - charcots disease

Question 3

Further investigations in diabetic foot examination?

Answer 3

Full neurovascular exam
Capillary blood glucose
Advise on appropriate footwear

Question 4

What to look out for on inspection of the lower limbs in a diabetic foot examination?

Answer 4

Peripheral cyanosis (PVD)
Peripheral pallor (poor perfusion)
Venous ulcers
Arterial ulcers
Neuropathic ulcers
Missing limbs or toes
Gangrene
Hair loss (PVD)
Foot calluses
Venous guttering - poor blood supply veins have guttered appearance

Question 5

What is Charcot arthropathy?

Answer 5

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:

Effusion
Distortion
Overlying erythema
Loss of joint function

Question 6

Monofilament sensation testing?

Answer 6

1. Provide an example of the monofilament sensation on the patient’s arm or sternum.
2. With the patient’s eyes closed, apply the monofilament to each of the following locations in turn:

The pulp of the hallux.
The pulp of the third digit.
Metatarsophalangeal joints 1, 3 and 5.

3. When applying the monofilament to each area:

Ask the patient to report when they feel the monofilament touch their foot - close eyes - say right/left?
Press the monofilament against the skin until it bends slightly (this will ensure that only 10g of pressure is applied).
Hold the monofilament against the skin for 1-2 seconds.
Avoid calluses and scars as they have a reduced level of sensation that is not representative of the surrounding tissue.

Question 7

Why do we assess gait in a diabetic foot assesment?

Answer 7

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. (peroneal nerve)

Question 8

Testing vibration sensation?

Answer 8

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.

Question 9

What does propioception test?

Answer 9

Dorsal columns (same as vibration)