# Diabetic Foot Examination

## Overview

This module describes how to examine the diabetic foot.

## Indications

Diabetic foot examinations should be performed:

1. Annually in patients with no lower limb complications
2. 3-6 monthly in patients with loss of protective sensation

## Contraindications

1. None

## Patient information and consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“People with diabetes often get problems with their feet such as numbness, injuries and infections. I’m going to examine your feet to ensure yours are healthy.”

### What can my patient expect?

“I’m going to take a good look at your feet, even between your toes, and I’m going to test your foot’s blood circulation and sense of touch.”

### What is my patient’s role?

“Please take off your socks and shoes. Tell me if anything is painful during the examination. Please remind your health care practitioner to check your feet regularly. You can also do it daily at home, or if you are unable to see properly, ask a caregiver to assist. If you have a regular caregiver, ask them to come with you to your next appointment to learn how to do it. I can also give you information on how to look after your feet to prevent problems developing.”

## Preparation

Prepare your equipment.

### Documentation

### Equipment

1. Alcohol-based hand rub
2. Non-sterile gloves if required
3. A 10 g monofilament
4. A tuning fork
5. A blood pressure cuff & stethoscope (or an automatic blood pressure monitor)
6. A Doppler probe

## Site & Positioning

This examination is best performed with the patient reclining, with their feet within easy reach. When testing with the monofilament, place a sheet or towel over the patient’s lower legs and the dorsum of the feet so that the patient cannot see the site.

## Procedure

Follow medical asepsis with non-sterile gloves.

1. Perform hand hygiene. Don non-sterile gloves.

2. Inspect the patient’s feet for

   dermatological changes
   dermatological changes

   Look for swelling, calluses, loss of sweating, ulceration, dry, cracked feet, nail changes and loss of hair on the lower legs and feet. Look for dried blood in the depths of any callus, which indicates a haemorrhage with possibly an ulcer under the callous. If left untreated, this could have detrimental consequences for the patient.

   , including between toes.

3. Inspect the patient’s feet for

   musculoskeletal abnormalities.
   musculoskeletal abnormalities.

   Look for deformities such as claw toes, hammer toes, overlapping toes, bunions, and Charcot's arthropathy.

4. Perform a monofilament test for peripheral neuropathy. First demonstrate by applying the monofilament to the skin of an arm until the filament buckles.

5. Apply the monofilament to the foot in the following places:

6. Ask the patient whether they feel the monofilament. Inability to feel the monofilament in any one position after three tries indicates loss of protective sensation.

7. Also perform mock tests to check for consistency and exclude that the patient is guessing. Pretend to touch the foot with the monofilament, then ask the patient if they are able to feel this.

8. Test one of the following:

   - vibration sensation: use the base of a tuning fork over a bony prominence.
   - pinprick sensation: apply a pin to the dorsum of the big toe, just proximal to the nail.
   - ankle reflexes: place the ankle in dorsiflexion. Tap the Achilles tendon with a patella hammer and look for contraction of the gastrocnemius muscle.

9. Palpate the dorsalis pedis and posterior tibial

   pulses.
   pulses.

10. If either pulse is absent, measure the

    ankle brachial index.
    ankle brachial index.

    Measure the brachial pressure (highest systolic blood pressure of the two arms).
    Measure the systolic pressure at the ankle using a BP cuff around the ankle, and a Doppler probe over the dorsalis pedis or posterior tibial. (Deflate the cuff until the pulse appears.)

    Divide the ankle pressure by the brachial pressure. <0.9, or >1.3 is abnormal.

11. Dispose of medical waste safely.

12. Document
    Document

    It is useful to place a sticker or a note in the patient's file: DIABETIC FOOT AT RISK. This reminds the clinician at the next visit to check the feet.

    the completion of the examination.

13. Advise the patient on their risk of diabetic foot disease, and on foot care.

## Troubleshooting

I don’t have a Doppler probe.

Use a stethoscope instead of a Doppler probe. If your institution has a midwife obstetric unit (MOU), they might have a handheld Doppler probe you can borrow.

## Risks

1. None

## References

1. Boulton AJ, Armstrong DG, Albert SF, Frykberg RG, Hellman R, Kirkman MS, et al. Comprehensive Foot Examination and Risk Assessment. Diabetes Care. Aug 2008;31(8):p 1679-1685.
2. Mishra SC, Chhatbar KC, Kashikar A, Mehndiratta A. Diabetic foot. BMJ. 2017;359:j5064.
3. Carmo GA, Mandil A, Nascimento BR, Arantes BD, Bittencourt JC, Falqueto EB, et al. Can we measure the ankle–brachial index using only a stethoscope? A pilot study. Family Practice. 2009;26(1)22–26.