1. Assessment of the diabetic foot; how I assess
Dr. Nalaka Gunawansa

2. Why perform a foot assessment?
Identify “the foot at risk”
Prevention of:
foot ulceration gangrene amputation
Assist in the maintenance of:
Mobility
Independence
Healthy active lifestyle
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

3. DIABETIC FOOT ASSESSMENT
COMPLETE HISTORY
MUSCULO-SKELETAL ASSESSMENT - deformities
NEUROLOGICAL ASSESSMENT
VASCULAR ASSESMENT – pedal pulses
DERMATOLOGICAL ASSESSMENT – tissues, callus, ulcers, necrosis etc.
INVESTIGATION – IMAGING, MICROBIOLOGICAL etc.

4. COMPLETE HISTORY Duration of diabetes, type of treatment,
Quality of glycaemic control
Other diabetes complications :
Renal / visual impairment,
hypertension,
Ischaemic heart disease,
strokes
Wound history
Functional impact of the wound
Previous foot ulceration/amputation
Neuropathic symptoms
Vascular symptoms
Social history & support

5. 1. THE MUSCULO-SKELETAL ASSESSMENT
Claw toes, hammertoe,
Pes Cavus
rocker bottom foot,
Hallux Rigidus
bunions and Charcot changes

6. 2. NEUROLOGICAL ASSESSMENT
Pain –Pin Prick Sensation
Pressure -10g Monofilaments
Vibration --128Hz Tuning Fork
Ankle Reflexes

7. NEUROLOGICAL ASSESSMENT
Designed to identify loss of protective sensation (LOPS) rather than early neuropathy.
Loss of sensation to the 10-g monofilament was associated with a 10-fold risk of foot ulceration and a 17-fold risk of amputation over a 32-month follow-up period
MONOFILAMENTS
At 6 sites on the sole in each foot, avoiding callus
perpendicular to the skin
pressure applied until the Monofilament buckles.
It should be held in place for <1 s and then
released.

9. 3. VASCULAR ASSESSMENT Absence / weak pulse mottling, dusky colour
cold foot,
shiny thin dry skin, atrophic nails, loss of hair on lower limbs

11. VASCULAR ASSESSMENT Taking temperature of the foot Palpate for pulses
Check the ABPI :
Normal Risk of foot ulcer is small
Definite vascular disease Risk of ulcer is moderate and
depends on other risk factors
Severe vascular disease < High risk of developing foot ulcer
Check the ToeBrachial Index <0.5 - Peripheral V Dis
Transcutaneous O2 tension
Duplex Scan

12. 4. DERMATOLOGICAL ASSESSMENT
Callus / ulcers
Location & dimensions
Look for sinus track, evidence of osteomyelitis and abscess
Assess the ulcer base :
Black : necrotic /
Yellow : slough
Pink : granulation tissue
Take note of slough, necrotic/gangrene tissue, dry exposed tendons/ligaments/fascia/joint capsule

13. STAGES OF ULCER DEVELOPMENT

15.  Assess depth of ulcer - probe - radiograph

16. ?

17. EXAMINE THE ULCER Check for evidence of infection :
Redness, swelling
discharge/pus
Culture and Sensitivity :
Ulcer swab – of limited value
Tissue – deep tissue biopsy
Bone fragments
Pus – after drainage of abscess

19. Interpreting Results

20. LABORATORY ASSESSMENT
PEDOGRAPHY
Pedographyis a dynamic measurement tool for the early recognition of the altered pressure patterns in the foot of diabetic patient
Patient walks barefoot across a platform with
thousands of calibrated pressure sensors,
each sensor will scan up to 400 times/sec and data is transmitted to the computer for analysis

22. GAIT ANALYSIS –SEE HOW THE PATIENT WALKS
Three dimensional analysis : > Comprehensive, Multisegment models
Detect imbalances which may be contributing towards the foot problems

24. WAGNER CLASSIFICATION
The most widely recognized classification is the Wagner system, which grades ulcers from 0 to 5 based largely on ulcer depth and severity
Although easy to remember, this system fails to address critical parameters like foot ischaemia, peripheral neuropathy, ulcer dimensions

28. DIABETIC FOOT ASSESSMENT
COMPLETE HISTORY
MUSCULO-SKELETAL ASSESSMENT - deformities
NEUROLOGICAL ASSESSMENT
VASCULAR ASSESMENT – pedal pulses
DERMATOLOGICAL ASSESSMENT – tissues, callus, ulcers, necrosis etc.
INVESTIGATION – IMAGING, MICROBIOLOGICAL etc.