1. Assessment of the diabetic foot
Dr. Nalaka Gunawansa

2. THE DIABETIC PATIENT’S FOOT
Every patient with diabetes has increased risk of developing foot ulceration which often leads to grave consequences
Needs to take all precautions to prevent this from happening
1 in 6 people with diabetes will have an foot ulcer during their lifetime.
At any one time, 3-4%
of diabetic patients
have a foot problem
( 2010 : 10 million )

3. Why perform a foot assessment?
Prevention of:
foot ulceration gangrene amputation
Assist in the maintenance of:
Mobility
Independence
Healthy active lifestyle
Assessment of the diabetic foot
DPMI Workforce Development – The Alfred Workforce Development Team June 2005

4. FOR THE PATIENT
Diabetics spend more time in the hospital for foot complications than for all other aspects of their disease combined
Immediate & long term morbidity
limb loss
psychological trauma
social impact
financial burden

5. DIABETIC FOOT ULCER -RISKS
The overall risk of an individual developing a diabetic foot ulcer is determined by a combination of factors which can be easily assessed and monitored :
Neuropathy
Peripheral Vascular Diseases
Poor diabetes control
Past history of foot ulceration /
amputation due to diabetes

6. CLINICAL ASSESSMENT
Many a times, we concentrate only on treating the foot ulcer, tried all means, get frustrated in the process, but forget to assess and tackle the many factors that contribute to its happening and stubbornness to heal and poor response to treatment

7. DIABETIC FOOT ASSESSMENT
COMPLETE HISTORY
NEUROLOGICAL ASSESSMENT
FOOT ASSESSMENT
EXAMINE THE ULCER
VASCULAR ASSESSMENT
NUTRITION & ENERGY REQUIREMENT ASSESSMENT
LABORATORY SCREENING

8. COMPLETE HISTORY
Previous foot ulceration/amputation, vascular surgery / angioplasty
a current ulcer indicates the patient is at “High Risk” of amputation
Smoking & exercise
Neuropathic symptoms : burning or shooting pain, electrical or sharp
sensations, numbness
Vascular symptoms :
claudication
rest pain,
Nonhealing ulcer
Social history & support,
Duration of diabetes, type of treatment received
Quality of glycaemiccontrol
Other diabetes complications : renal insufficiency,
visual impairment,
hypertension,
ischaemicheart disease,
strokes
Initial wound formation and treatment received
Functional impact of the wound on the patient

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

10. FOOT ASSESSMENT Remove the shoes and socks Check BOTH feet
Check the appropriateness of the shoes
Check the shoes for correct size & depth & width, abnormal wear patterns, seams, ridges or other areas of friction or pressure
Foot care hygiene practices

11. FOOT ASSESSMENT Look for oedema, cyanosis, hyperaemia dependent rubor
Ingrowing toe nails,
paronychia
cracks, ulceration, callus, deformity,
healed scars, loss of toes & signs of infection

12. Assess the foot for deformity :
Claw toes, hammertoe,
Pes Cavus
rocker bottom foot,
Hallux Rigidus
bunions and Charcot changes
Look for callus :
Ulcer may be embedded under thickened callus over areas like big toe, heel, metatarsal heads

13. Look for signs of foot ischaemia:
mottling, dusky colour, cold foot,
shiny thin dry skin,
atrophic nails
loss of hair on lower limbs

14. EXAMINE THE ULCER Very important for treatment
Check the location & dimensions of ulcer
Look for sinus track, evidence of osteomyelitis and abscess
Assess the ulcer base :
Black : necrotic /
eschar
Yellow : slough
Pink : granulation tissue
Take note of slough, necrotic/gangrene tissue, dry exposed tendons/ligaments/fascia/joint capsule

15. EXAMINE THE ULCER Check for evidence of infection : sequestrum
redness
swelling
discharge/pus
abscess
sequestrum
Sometimes, deep infection may have
deceptively few superficial signs

16. 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

18. GAIT ANALYSIS –SEE HOW THE PATIENT WALKS
NORMAL FOOT : Complex kinematics
DIABETIC FOOT : Altered biomechanics . Every foot is different & the spectrum and degree of abnormalities changes over time
Two dimensional gait analysis : older model, more rigid
Three dimensional analysis : > Comprehensive, Multisegment models
Detect imbalances which may be contributing towards the foot problems

19. VASCULAR ASSESSMENT Taking temperature of the foot Palpate for pulses
Check the ABSI :
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

20. Pedal Pulse :
however, the presence of palpable pulses DOES NOT absolutely exclude peripheral arterial disease.

21. TRANSCUTANEOUS O2 TENSION
Important factors in the healing process include not only macrocirculation, but more specifically, the local skin micro circulation and oxygenation of the tissue surrounding the ulcer

22. DUPLEX ULTRASOUND & ANGIOGRAPHY
Duplex ultrasound and angiography can show areas of vascular stenoses or occlusions & measure blood flow velocity & turbulance

23. LASER DOPPLER FLOWMETRY
Non-invasive & highly accurate
Enables the user to image changes in blood flow over the entire wound surface, with a full colour 2-dimentional map of Microvascular flow

25. NUTRITION & ENERGY REQUIREMENT ASSESSMENT
Poor diet and glycaemicvcontrol leads to hyperglycaemia
Impaired utilization of carbohydrate due to hyperglycemia leads to more proteolysis,
glycogenolysis, and lipolysis and subsequent decreased wound healing
Hyperglycemia also leads to osmotic diuresis and the loss of water and electrolytes
Both extracellular and intracelluardehydration occurs

26. Measure height, weight, BMI & ideal body weight
Determine activity types and frequency
Determine limitations that hinder exercise
Assess willingness and ability to be more physically active
Determine use of vitamin/minerals/nutrition supplements
Assess for eating disorders

27. LABORATORY SCREENING HbA1c > 10% : Random / Fasting sugar
risk of infection and poor wound healing
Random / Fasting sugar
Renal Function
Liver Function, Serum Albumin
Full blood count : Hb, Total White
ESR, CRP

28. Culture and Sensitivity :
Ulcer swab
Tissue
Bone
Pus
Histopathology
Useful for diagnosis of osteomyelitis
Biopsy of chronic non healing ulcer : Marjolin’s Ulcer Squamous Cell Ca, Malignant Melanoma

29. 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

31. Slides from the pdf files

32. 60-second Diabetic Foot Screen

34. Instructions for Use
Step 1: Explain screening to the patient and have them remove their shoes, socks from both feet.
Step 2: Remove any dressings or devices that impair the screening.
Step 3: Review each of the parameters for each foot as listed in the Inlow’s 60-second Diabetic Foot Screen and select the appropriate score based
on patient’s status. (An amputation may affect the score on the affected limb.)
Step 4: Once the screen is completed determine care recommendations based on patient need, available resources and clinical judgement.
Step 5: Use the highest score from either the left or right foot to determine recommended screening intervals.
Step 6: Set up an appointment for the next screening based on screening score and clinical judgement.

35. Parameter Review
1. Skin
Assess the skin on the foot: top, bottom and sides including between the
toes.
0 = skin is intact and has no signs of trauma. No signs of fungus or
callus formation
1 = skin is dry, fungus such as a moccasin foot or interdigital yeast
may be present. Some callus build-up may be noted
2 = heavy callus build-up
3 = open skin ulceration present

36. 2. Nails
Assess toenails to determine how well they are being managed either by
the patient or professionally.
0 = nails well-kept
1 = nails unkempt and ragged
2 = nails thick, damaged or infected
3. Deformity
Look for any bony changes that can put the patient at significant risk and
prevent the wearing of off-the-shelf footwear
0 = no deformity detected
2 = may have some mild deformities such as dropped metatarsal heads(MTHs) (the bones under the fat pads on the ball of the foot).Each MTH corresponds to the toe distal to it, so there is a 1.MTH at the base of the first toe etc. Bunions/Charcot may also beconsidered a deformity as well as deformities related to trauma.
4 = Amputation

37. 4. Footwear
Look at the shoes that the patient is wearing and discuss what he or she normally wears.
0 = shoes provide protection, support and fit the foot. On removal of the footwear there are no reddened areas on the foot
1 = shoes are inappropriate do not provide protection or support for the foot.
2 = shoes are causing trauma (redness or ulceration) to the foot either through a poor fit or a poor style (eg., cowboy boots).
5. Temperature – cold
Does the foot feel colder than the other foot or is it colder than it should be considering the environment? This can be indicative or arterial disease.
0 = foot is of “normal” temperature for environment.
1 = foot is cold – compared to other foot or compared to the environment

38. 6. Temperature – hot
Does the foot feel hotter than the other foot or is it hotter than it should
be considering the environment? This can be indicative of an infection or
Charcot changes.
0 = foot is of “normal” temperature for environment
1 = foot is hot – compared to other foot or compared to the environment
7. Range of Motion
Move the first toe back and forth – plantar flex and dorsiflex.
0 = first toe (hallux) is easily moved
1 = hallux has some restricted movement
2 = hallux is rigid and cannot be moved
3 = hallux amputated

39. 8. Sensation – Monofilament testing
Using the 5.07 monofilament, test the sites listed. Do not test over heavy callus.
• digits: 1st, 3rd, 5th
• MTH: 1st, 3rd, 5th
• midfoot: Medial, Lateral
• heel
• top (dorsum) of foot
And then score out of 10:
0 = 10 out of 10 sites detected
2 = 7 to 9 out of 10 sites detected
4 = 0 to 6 out of 10 sites detected

40. 9. Sensation – Questions
Ask the following four questions:
i. Are your feet ever numb?
ii. Do they ever tingle?
iii. Do they ever burn?
iv. Do they ever feel like insects are crawling on them?
0 = answered No to all four questions
2 = answered Yes to one or more of the four questions
10. Pedal pulses
Palpate (feel) the dorsalis pedis pulse located on the top of the foot. If unable to feel the pedal pulse feel for the posterior tibial pulse beneath the medial malleolus.
0 = pulse present
1 = pulse absent

41. 11. Dependent rubor
Pronounced redness of the feet when the feet are down and pallor when the feet are elevated. This can be indicative of arterial disease.
0 = no dependent rubor
1 = dependent rubor present
12. Erythema
Look for redness of the skin that does not change when the foot is elevated. This can be indicative of infection or Charcot changes.
0 = no redness of the skin
1 = redness noted

42. Interpreting Results

43. Determining Risk
Step 1: Complete Inlow’s 60-second Diabetic Foot Screen by assessing both feet on every patient with diabetes.
Step 2: Using the IWGDF Risk Classification System, identify which category your patients falls into.

44. From PDF

45. GENERAL INSPECTION

46. DERMATOLOGICAL ASSESSMENT
The dermatological assessment should initially include a global inspection,( interdigitally also), for the presence of ulceration or areas of abnormal erythema.
The presence of callus (particularly with haemorrhage), nail dystrophy, ingrown toe nail or paronychiacshould be recorded14, Focal or global skin temperature differences between one foot and the other may be predictive of either vascular disease or Cellulitis associated with or without ulcer.
Local Skin temperature can be judged crudely by
back of the hand otherwise Laser Thermometer
is ideal and more precise.

47. Foot deformities lead to high pressure areas leading to diabetic foot ulceration.
Common forefoot deformities that are known to increase plantar pressures and are associated with skin breakdown include claw toe or hammer toe16-18.
An important and often overlooked or misdiagnosed condition is
Charcot arthropathy.
This occurs in the neuropathic foot and most often affects the mid foot.
This may present as
a unilateral red, hot,
swollen, flat foot with profound deformity.
A rocker-bottom deformity secondary to Charcot arthropathy can cause
excessive pressure at the plantar mid foot, increasing risk for ulceration
at that site.

49. NEUROLOGICAL ASSESSMENT
The clinical exam recommended, however, is designed to identify loss of protectivem sensation (LOPS) rather than early neuropathy.
MONOFILAMENTS
sometimes known as Semmes-Weinstein
monofilaments, were originally used to diagnose sensory loss in leprosy
10-g monofilament test, the device is placed
perpendicular to the skin, with pressure applied until the Monofilament buckles. It should be held in place for <“1 s and then
released.

50. Monofilaments
Sometimes known as Semmes-Weinstein monofilaments, were originally used to diagnose sensory loss in
leprosy23.
Many prospective studies have confirmed that loss of pressure sensation using the 10-g monofilament is highly predictive of subsequent ulceration.
Screening for sensory loss with the 10-g monofilament is in widespread use across the world, and its efficacy in this regard has been confirmed in a number of trials, including Seattle Diabetic Foot Study6.
A prospective study published in Diabetes Care in 1992 showed the loss of sensation to the 10-g ûlament on the sole of the foot was associated with a 10-fold risk of foot ulceration and a 17-fold risk of amputation over a 32-month follow-up period
The most important areas to assess are uncallused regions of the plantar surface of the metatarsal heads

51. Nylon monofilaments are constructed to buckle when a 10-g force is applied;
loss of the ability to detect this pressure at one or more anatomic sites on the plantar surface of the foot has been associated with loss of large-fibre nerve function.
It is recommended that six sites (1st, 3rd, and 5th metatarsal heads, plantar surface of distal hallux, Instep & Heel) be tested on each foot while the patient’s eyes are closed.
For performance of the 10-g monofilament test, the device is placed perpendicular to the skin, with pressure applied until the monofilament buckles.
It should be held in place for <“1 s and then released.
Single-use disposable monofilaments or those shown to be accurate by the Booth and Young study are recommended.
The sensation of pressure using the buckling 10-g monofilament should first be demonstrated to the patient on a proximal site (e.g., upper arm).
The sites of the foot may then be examined by asking the patient to respond “yes” or “no” when asked whether the monofilament is being applied to the particular site; the patient should recognize the perception of pressure as well as identify the correct site.
Areas of callus should always be avoided when testing for pressure perception.

52. PINPRICK SENSATION ANKLE REFLEXES
Inability of a subject to perceive pinprick sensation has been associated with an increased risk of ulceration.
A disposable pin should be applied just proximal to the toenail on the dorsal surface of the hallux, with just enough pressure to deform the skin.
Inability to perceive pinprick over either hallux would be regarded as an abnormal test result.
ANKLE REFLEXES
Ankle reflexes can be tested with the patienteither kneeling or resting on a couch/table. The Achilles tendon should be stretched until the ankle is in a neutral position before striking it with the tendon hammer.
If a response is initially absent, the patientcan be asked to hook fingers together and pull, with the ankle reflexes then retested with reinforcement. Total absence of ankle reflex either at rest or upon reinforcement is regarded as an abnormal result.

54. TUNING FORK TEST
The tuning fork of 128-Hz is widely used in clinical practice and provides an easy and inexpensive test of vibratory sensation.
Vibratory sensation should be tested over the tip of the great toe bilaterally.
An abnormal response can be defined as when the patient loses vibratory sensation and the examiner still perceives it while holding the fork on the tip of the toe
VPT (VIBRATION PERCEPTION THRESHOLD) TESTING
The biothesiometer (or neurothesiometer) is a simple handheld device that gives semi quantitative assessment of vibration perceptio threshold (VPT).
Vibration perception using the biothesiometer is also tested over
the six points over plantar surface
A VPT >15 V is regarded as abnormal and higher VPT
readings has been shown to be strongly
predictive of subsequent foot ulceration

55. CIRCULATORY ASSESSMENT
Peripheral arterial disease (PAD) is a component cause in approximately one-third of foot ulcers and is often a significant risk factor associated with recurrent wounds.
Assessment of peripheral circulation in diabetic patients includes thecstandard evaluation for pedal pulses ; however, examiner s shouldcbe aware of the possible pitfalls of using presence of pulses alone to exclude clinically signiûcant peripheral ischemia.
Vascular examination should include
palpation of the posterior tibial and dorsalis pedis pulses “present” or “absent”.
non invasive measures of circulation are frequently used to complement physical examination in assessing the degree of arterial obstruction.
More reliable methods of assessing potential for healing foot ulcers in diabetic patients suspected of having peripheral ischemia involve measurement of
Ankle Brachial Index,
systolic toe pressure
distal transcutaneous oxygen tension

56. ANKLE BRACHIAL INDEX (ABI)
Diabetic patients with signs or symptoms of vascular disease(like Intermittent claudication, Rest Pains, nocturnal pain, cold feet, blanching on elevation of limb & rubor on dependency, delayed capillary filling, Impending tissue loss or established gangrene) or
absent pulses on screening foot examination should undergo ankle
brachial pressure index (ABI) pressure testing .
The ABI is a method of diagnosing vascular insufficiency in the lower limbs. Blood pressure at the ankle (dorsalis pedis or posterior tibial arteries) is measured using a standard Doppler ultrasonic probe.
The ABI is obtained by dividing the ankle systolic pressure by the higher of the two brachial systolic pressures.
ABI >0.9 to <1.3 is normal
ABI <0.8 is associated with claudication
<0.4 is commonly associated with ischemic rest pain and tissue necrosis.

59. PDF file

60. THE PATHWAY TO FOOT ULCERATION
The lifetime risk of a person with diabetes developing a foot ulcer may be as high as 25%, whereas the annual incidence of foot ulcers is 2% .
Up to 50% of older patients with type 2 diabetes have one or more risk factors for foot ulceration.
A number of component causes,most importantly peripheral neuropathy,interact to complete the causal pathway to foot ulceration.
The most common triad of causes that interact and ultimately result in ulceration has been identified as neuropathy, deformity, and trauma