Diabetes foot exam

• Preparation
• Expose lower legs and feet
• Equipment:
  • 10g monofilament
  • 128 Hz tuning fork
• Inspection
  • Signs of peripheral arterial disease
    • Decreased hair, skin atrophy, ulcers with “punched out” appearance over toes, distal foot and heel
  • Deformity of foot
    • Claw toes, excess callus, weight dependent ulcer
    • Charcot foot: collapsed foot arch, erythema, edema, warmth
  • Signs of infection
    • Onycholysis of nails
    • Cellulitis of skin
    • Infected ulcers
    • Potential osteomyelitis
  • Skin findings
    • Necrobiosis lipoidica diabeticorum
      • Yellow scarring with red margins - on shins
    • Diabetic dermopathy
      • small plaques with raised borders over shins
• Test for diabetic neuropathy
  • 10g monofilament test
    • Introduce test
    • Appy tip to pt’s forehead or sternum to ensure pt can sense monofilament
    • Instruct pt to close eyes
    • Apply monofilament 4 times to each great toe
      • Skin proximal to nail bed of great toe
      • Ensure filament bends for 1 sec before lifting from skin
    • Arrhythmic fashion
    • Ask pt to say “yes” each time
    • Score: 0=nosensation, 0.5=reduced sensation, 1=full sensation
    • Score of <=3 suggest probable neuropathy, 3.5-5 is risk of neuropathy
  • 128Hz vibration fork
    • Strike tuning fork on solid surface
    • Apply fork to pt’s forehead or sternum to ensure pt can sense normal vibration
    • Instruct pt to close eyes
    • Apply base of fork to skin proximal to nail bed of great toe
    • Ask pt to state when they no longer sense vibration, then dampen fork with other hand
    • Score
      • 1 pt for correct vibration sensation
      • 1 pt for correct sensation of vibration cessation
    • Repeat on same foot, then 2x on other foot
• Palpation
  • Temperature
    • Use back of hands
  • Capillary refill
    • Press nail of great toe until blanches and then release
    • Normal refill 3-4 seconds
  • Pulses
    • Dorsalis Pedis
      • Lateral to tendon of ext hallucis longus
    • Posterior Tibial
      • Posterior to medial malleolus
    • Popliteal
      • Popliteal space - with knee flexed
    • Femoral
      • Between ASIS and symphysis pubis
    • Grading: 0=none; 1+ diminished; 2+ normal; 3+ bounding
• Special tests
  • Pallor on elevation
    • Pt supine
    • Elevate one leg and hold for 1 minute
    • Marked pallor may indicate arterial insufficiency
  • Rubor on dependency
    • After “pallor on elevation”
    • Gently drop leg over side of bed
    • Colour of plantar surface of foot
      • Should return to same colour of non-elevated leg within seconds
      • Rubor (marked redness) = arterial dilation in response to tissue hypoxia

Rational Clinical exam