Diabetic Foot Examination

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Introduction

  • Wash Your hands
  • Introduce yourself by name and Role
  • Check the patient’s identity – name and Date of Birth
  • Explain the procedure – why you need to do it and what does it involve
  • Ask for consent
  • Expose the patient appropriately
  • Check if the patient is currently in any pain
How to Introduce Yourself

“Good morning, my name is .. and I am a medical student. Can I just check your name and date of birth?

I have been asked to do a diabetic foot examination on you, which would involve having a look at you walk, having a look at your feet and testing your sensation.

For this examination would you mind undressing from waist below keeping your underwear on.

– Before I start, can I check whether you are in any pain?” 

Bedside Inspection

  • Observe the patient by standing at the end of the bed.
  • Comment on whether the patient is ABC:

A – Alert         B – (normal) Body habitus         C – Comfortable at rest

  • Observe the surroundings: “any walking aids, special footwear, orthotics, blood sugar monitoring”

This is a description of the objects or items around a patient’s bedside that will give you an idea into the condition that they might have. It is important to highlight this to the examiner as this can give you many clues about the patient’s underlying diagnosis. Things to look for include: 

  • Oxygen – is the patient currently on oxygen or room air, and what is the flow rate?
  • Medication – can you see any medication on the patient’s bedside e.g. insulin?
  • Test results – are there any investigation results like ECGs lying around the patient’s bedside.
  • Fluid chart – this gives you an idea if they are fluid overloaded.
  • Mobility aids – gives an idea about the functional status of the patient.
  • Orthotic – These are special comfortable shoes that patients with diabetes wear to reduce pressure on the feet.

 

Gait

Action: Ask the patient to walk to the end of the room, turn around and then walk back.

Assess for:

–> Smoothness: Is there any disruption to the normal gait cycle such as abnormalities in toe-off or heel strike?

–> Symmetry: Is the gait symmetrical on both sides? Asymmetry of the gait could be caused by problems such as leg-length discrepancy, fixed flexion deformity, or pain on one side which reduces full extension and weight bearing on that side.

–> Step Height: A damage to the common fibular nerve for example leads to a foot-drop on the affected side. This means the patient will not be able to dorsiflex which gives them a high step height to compensate.

Types of Gait

The gait cycle is made up of 6 phases.

  1. Heel-strike: this is when the heel first touches the floor.
  2. Foot flat: here the weight is transferred onto the leg as the foot is all in contact with the floor.
  3. Mid-stance: the weight is aligned and balanced on this leg.
  4. Heel-off: Here the heel lifts off as you start to transfer weight onto the other leg.
  5. Toe-off: this is when the toes finally lift off the floor
  6. Swing: the foot swings forward until the heel comes back in contact with the ground restarting the cycle.

a) Antalgic gait – A type of gait where the stance phase is abnormally shortened to reduce time on that foot. It looks like a limp –> Implies pain in that leg

b) Waddling gait – This is due to weakness of the proximal muscles of pelvis which causes weakness of gluteus muscles. Patient moves upper body forwards and drags lower leg forward.

c) Spastic gait – this is described as a swinging gait where the patient swings his leg round as it is hyperextended. This is seen in UMN lesions such as stroke

d) High-stepping gait – This is due to damage of the deep branch of the common fibular nerve which leads to foot-drop due to loss of dorsiflexion. This means the patient has a high step in order to compensate.

e) Trendelenburg Gait – this leads to dropping of the pelvis on the contralateral side when you are walking. It is due to damage to the gluteus medius on the supported side –> indicates a lesion of the superior gluteal nerve

f) Parkinson gaitshuffling steps with a stooped over posture. The patient will shuffle forward with lack of arm swing. They will need many small steps to turn around. The gait can appear rushed, and then also freeze.

g) Ataxic gait – this is a gait that looks like someone has just learnt how to walk. The person will watch their feet and walk like a spaceman with a wise stance so that they do not fall over. It is associated with an ataxia, usually due to cerebellar dysfunction. 

Action – Perform Romberg’s test of balance.

a. Position yourself within arms reach of the patient to allow you to intervene should they begin to fall.

b. Ask the patient to put their feet together and keep their arms by their sides (be aware that patients with truncal ataxia may struggle to do this, however, this type of unsteadiness is not the same as a positive Romberg’s sign).

c. Ask the patient to close their eyes.

Assess for:

–> Balance – this is a test which can be used to assess whether there is a problem with proprioception or the cerebellum. 

– If patient feels unsteady with eyes closed – this is a positive Romberg’s  sign. This shows problem is due to sensory problem (due to proprioceptive disorder or vestibular dysfunction)

– If patient feels unsteady with eyes open – this is a negative Romberg’s sign. This shows problem is in the cerebellum, due to an issues with coordinating the different sensory inputs. 

Action: Inspect the patient’s shoes carefully

Assess for:

–> Soles and padding: People with diabetes may have extra padding in their shoes to reduce pressure on the feet. This is because due to the peripheral neuropathy, they are more at risk at putting overpressure on particular areas which can lead to the development of ulcers. 

    Diabetes Shoes

    Legs

    INSPECTION

    Action: Ask the patient to keep their legs outstretched. Closely inspect their feet and legs for any signs of cardiovascular disease.

    Assess for:

    –> Scars: Look for vein harvesting scars for a CABG. The great saphenous vein is often used as the graft for a coronary bypass surgery, so this will indicate that the patient has ischaemic disease. 

    –> Varicose veins: These are dilated and tortuous veins secondary to chronic venous insufficiency

    –> Peripheral Cyanosis: This is a blue discolouration of the nails and fingers which is indicative of peripheral ischaemia. It shows the patient is peripherally not perfusing well which can be seen in shock or hypothermia. 

    –> Trophic Changes: These are cutaneous changes that appear due to diabetes and peripheral neuropathy. They often start off as callous formation but also include shiny skin, loss of hair.

    –> Ulcers: Describe margin, colour, wet/dry and location

    –> Loss of digits: These are a consequence of end organ ischaemia which may have resulted in the digits being amputated. Therefore it is important to count the number of digits in the hands. 

    –> Charcot joint: Consequence of diabetic neuropathy

    Varicose Veins

    Associated with venous insufficiency

    Neuropathic Foot Ulcer

    Associated with moderate-severe diabetes

    Venous Ulcer

    Associated with moderate-severe diabetes

    Vein Harvesting Scar

    Associated with cardiovascular surgery e.g. CABG

    Charcot Joint

    Associated with peripheral neuropathy

    Palpation

    Action: Ask the Patient to keep their legs outstretched. Using the back of your hands, feel down from their thighs to feel the temperature:

    Assess for:

    –> Cold peripheries: This is a sign of poor peripheral circulation. This is a common sign of shock and so may occur in hypovolaemia when the arterioles are vasoconstricted to reduce blood supply to the extremities. 

    Action: Pinch the patient’s toenail for 5 seconds and then release. Measure the capillary refill time.

    Assess for:

    –> Capillary refill time: This is the time taken for the capillaries to refill after a sustained period of pressure. Apply 5 seconds of pressure to the distal phalanx of the index finger and then release. Count how many seconds it taken to go red (re-vascularise). If >2 seconds, this shows poor peripheral circulation which could be a sign of shock. 

     

    Pulses

    Action: Ask to lower patient’s boxers. Compare the pulses side by side.

    Assess for:

    –> Femoral pulse: This is found in the femoral triangle. Mention if you can feel it or not, the volume and whether you can listen to any bruits.

    –> Popliteal Pulse: Assess this pulse with the knee flexed for 45 degrees

    –> Posterior tibial: This pulse is found 1cm posterior to the medial malleolus.

    -> Dorsalis pedis: This pulse is detected on the dorsum of the foot between the 2nd/3rd cuneiform bones

     

    Sensation

    Testing for sensation is essential as it can help distinguish whether the patient has diabetic neuropathy. This puts them at increased risk of developing neuropathic ulcers due to the loss of sensation on particular pressure points of the feet. We assess this using a monofilament which applies pressure to parts of the feet. 

    With sensation, you want to characterise the distribution of sensory changes.

    You will also want to test different modalities, proprioception and vibration.

    Pressure

    In order to assess pressure we use a monofilament – this is needed as it is calibrated to apply 10g of pressure. To use it properly, open the monofilement fully so that the whole end is exposed. Push the monofilament against the skin so you can see it bend visibly. Hold it there for 1-2 seconds before removing it from the skin. 

    Action: Use a monofilament to assess the pressure sensation of the patient’s feet.

    a. Using the monofilament, press on the patient’s sternum to give them an idea of what it will feel like

    b. Ask the patient to close their eyes. Tell them you will press the monofilament on areas of their feet and they should say “yes” when they can feel something.

    c. Press the monofilament in particular areas of the feet. In order, they are:

    – Pulp of the hallux

    – Pulp of middle toe

    – Metatarsophalangeal joints of 1st, 3rd and 5th digits. 

    d. Repeat this on the other foot. 

    Assess for:

    –> Pressure sensation: Pressure is carried by large myelinated Aa and Ab fibres. Diabetes and poor peripheral circulation causes microvasculature changes which impair these fibres from working leading to reduced pressure sensation, particularly in the feet. This makes patients at risk of developing neuropathic ulcers. 

     

    Using a Monofilament

    Applies 10g of pressure

    Testing areas

     

    – Pulp of the hallux

    – Pulp of middle toe

    – Metatarsophalangeal joints of 1st, 3rd and 5th digits.

    Diabetic Ulcer

    Associated with moderate-severe diabetes

    Vibration

    Vibration and pressure are transmitted by large Aa and Ab fibres which travel in the dorsal column of the spinal cord. They are affected by many conditions, including diabetes. 

    Action: Test for the sense of vibration using a tuning fork. 

    a. Tap the tuning fork so it vibrates

    b. Ask the patient to close their eyes and place the end of the tuning fork on their sternum, to show them what it will feel like. 

    c. Tell them you will now place it elsewhere and that they need to tell you when they can feel it vibrating and when it stops. 

    d. Tap the tuning fork and place the end on the distal interphalangeal joint of the big toe. 

    e. See if the patient can correctly tell you when it vibrates and when the vibration has stopped.

    Assess for:

    –> Sense of vibration: If they answer you correctly, you do not need to continue. 

    – If they cannot answer at the big toe, work more proximal repeating the test at the metatarsophalangeal joint, then ankle and then knee.  

    Proprioception

    Proprioception is the sense of where you limbs are in space. It relied on joint fibres which gives sensory input to the brain allowing the brain to form an image of the body in space. It is affected by neuropathies which affect nerve fibres which travel in the dorsal column of the spinal cord. 

    Action: 

    a. Hold the patient’s big toe by the distal phalangeal joint on both sides (not compressing the nail bed). 

    b. With the patient watching , move the toe “up” and then “down” so the patient understands which way is which.

    c. Ask the patient to close their eyes

    d. Move the toe up and down, each time asking the patient which way you are moving it. 

    Assess for:

    –> Sense of proprioception: If they answer you correctly, you do not need to continue. 

    – If they cannot answer at the big toe, work more proximal repeating the test at the metatarsophalangeal joint, then ankle and then knee. 

    Ankle Reflex

    Action: Test for the ankle-jerk reflex (S1) in both of the patient’s legs, one by one

    a. Ask the patient to bring their knee up and then drop their leg to the side. This will bend their leg as if they are making a frog’s leg on that side. The hip is abducted, knee flexed and the ankle held in dorsiflexion.

    b. Keep the ankle slightly dorsiflexed so their achilles tendon is stretched

    c. Using the tendon hammer, tap the Achille’s tendon

    d. See if you can feel a reflex contraction in the gastrocnemius muscle causing the foot to plantarflex. 

    Assess for:

    –> Hypo/hyperreflexia: LMN associated with hypo and UMN associated with hyper.  

    Thank the patient and wash your hands to complete the examination!

    On Completion

    I would like to do a full history, a full set of observations and peripheral vascular and lower limb neurological examination

    “To complete the examination, I would do a number of steps…”

    Bedside – (History) Take a full history

    • (Observations) Full set of observations including blood pressure
    • (Corresponding examination) Conduct a peripheral vascular and lower limb neurological examination
    • (Bedside tests) Would do a point-of-care glucose measurement + Urine dipstick
    • (Formal Investigations) HbA1c + Urine for albumin:creatinine ratio + Lipid profile
    • (Special tests) ABPI with doppler ultrasound + CT/MRA (if indicated)
    How to Present Your Findings

    – Today I performed a diabetic foot examination on Mr/Miss… a [age] male/female

    – Bedside examination revealed paraphernalia/no paraphernalia of endocrine pathology

    – The patient appeared alert, with a normal body habitus, comfortable at rest

    – A peripheral examination revealed (no) stigmata of diabetic disease/ There was evidence of…

    – Inspection of the legs revealed…

    – Palpation of the legs revealed…

    – Examination of the pulses of the lower limb revealed

    – The sensory examination was…

    – The ankle reflex was…

    – In summary this was a normal diabetic foot examination.”

    Sources

    Gait Cycle –  Ducky2315, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

    Diabetes Shoes – Brainy J, CC0, via Wikimedia Commons

    Varicose Veins – self, Public domain, via Wikimedia Commons

    Neuropathic Ulcer – Mark A. Dreyer, DPM, FACFAS, CC BY 4.0 <https://creativecommons.org/licenses/by/4.0>, via Wikimedia Commons

    Venous Ulcer – Nini00, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

    Vein Harvesting – Timpo, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

    Charcot Joint – J. Terrence Jose Jerome, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons

    Using a MonofilamentServier Medical Art, CC BY 2.0 <https://creativecommons.org/licenses/by/2.0>, https://www.flickr.com/photos/serviermedicalart/9700640600

    Testing Areas – Assessment of sensory neuropathy in patients with diabetic foot problems – Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Showing-the-10-sites-in-the-foot-for-507-Semmes-Weinstein-monofilament-testing-SWMT_fig2_221683581, Creative Commons Attribution-NonCommercial 3.0 Unported

    Diabetic UlcersMoreMed, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons

    Ankle ReflexMalays J Med Sci. 2021 Apr; 28(2): 48–62. Published online 2021 Apr 21. doi: 10.21315/mjms2021.28.2.5. Copyright © Penerbit Universiti Sains Malaysia, 2021. This work is licensed under the terms of the Creative Commons Attribution (CC BY) (http://creativecommons.org/licenses/by/4.0/).

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