Download Physical Assessment of the Diabetic Foot

MARCH/APR IL 2003
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Physical Assessment of the Diabetic Foot
C M E
C AT E G ORY 1
1 Hour
A NC C / AA CN
3.0 Contact Hours
Steven R. Kravitz, DPM, FACFAS, FAPWCA • Executive Director, American Professional Wound Care Association • Richboro, PA •
Assistant Professor and Staff Member, Wound Healing Center • Temple University School of Podiatric Medicine • Philadelphia, PA
James McGuire, DPM, PT, FACFAS, FAPWCA • Chairman, Department of Medicine and Director, Wound Healing Center • Temple
University School of Podiatric Medicine • Philadelphia, PA • Advisory Board Member, American Professional Wound Care Association •
Richboro, PA
Sean D. Shanahan, DPM, MPH • Podiatric Resident • Warminster Hospital • Warminster, PA
Steven R. Kravitz, DPM, FACFAS, FAPWCA, has disclosed that he is a consultant for PALHealth Systems, Pekin, IL. James McGuire,
DPM, PT, FACFAS, FAPWCA, has disclosed that he is a consultant for Silipos Corporation, Niagra Falls, NY. Sean D. Shanahan, DPM,
MPH, has disclosed that he has no significant relationships or financial interests in any commercial companies that pertain to this educational activity.
Submitted November 26, 2002; accepted January 24, 2003.
PURPOSE: To provide physicians and nurses with an overview of diabetic foot assessment.
TARGET AUDIENCE: This continuing-education activity is intended for physicians and nurses with an interest in learning about proper diabetic foot assessment.
OBJECTIVES: After reading the article and taking the test, the participant will be able to:
1. Review the epidemiology of diabetes, diabetic foot ulcers, and lower-extremity amputation related to diabetes.
2. Identify risk factors for foot ulceration in patients with diabetes.
3. Identify normal and abnormal findings in the dermatologic, vascular, neurologic, and musculoskeletal assessment of
the foot in patients with diabetes.
ADV SKIN WOUND CARE 2003;16:68-77.
he most common wounds of the lower extremity are
venous, diabetic, neuropathic, ischemic, and pressure
ulcers.1 The quintessential assessment of any patient
with a lower-extremity ulcer is a comprehensive history, physical assessment, and the use of special procedures or laboratory tests to arrive at a differential or specific diagnosis.This standard process is almost an art form because, although there are
established protocols that should be followed in sequence,
each individual patient presents with a unique set of circum-
stances that makes strict adherence to a formula almost impossible.This is especially true for patients with diabetes.
The secondary manifestations of diabetes, which affect the
distal extremities, are well known. Under normal conditions,
the peripheral neurovascular system provides sensation, proprioception, nutrition, oxygenation, and vascularization; it also
allows for locomotion and protection from the environment.
Diabetes (and its secondary complications) is particularly damaging to the afferent neurobiology of the peripheral neurovas-
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ADVANCES IN SKIN& WOUND CARE • VOL.16 NO. 2
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cular system, often resulting in a loss of protective sensation,
foot and digital deformities, or a marked reduction in vascular
perfusion of the lower extremity. As a result, the biomechanically altered, insensate, dysvascular foot is at high risk for
ulceration and/or infection.
85% of diabetes-related amputations are preceded by the
appearance of a foot ulcer.8
According to the National Institute of Diabetes and
Digestive and Kidney Diseases, an average of 54,000 diabetic
amputations were performed each year between 1989 and
1992. In addition,National Hospital Discharge Survey data for
1996 indicated that 86,000 people with diabetes underwent 1
or more lower-extremity amputations.9 The total annual cost
for these amputations was more than $1.1 billion dollars,
excluding surgeons’fees, rehabilitation costs, prostheses, time
lost from work, and disability payments.10 Furthermore, in a
1995 study, the average individual cost of a minor amputation
averaged $43,000 and a major amputation cost $65,000.11
EPIDEMIOLOGY
Diabetes is the sixth leading cause of death in the United
States.2 From 1990 to 1998, the prevalence of diabetes
increased from 4.9% to 6.5%.3 About 800,000 cases of diabetes
are diagnosed in the United States each year. Approximately 17
million Americans—6.2% of the population—have diabetes,
5.9 million of them undiagnosed.Another 16 million have prediabetes (impaired glucose tolerance).4 The objective of
Healthy People 2000 was to reduce the incidence of diabetes to
2.5 cases per 1000 people and reduce prevalence to 25 cases per
1000 people.5 Because these objectives were not met,they were
renewed for Healthy People 2010.6
Healthy People 2010 has 3 objectives specifically related to
foot care for individuals with diabetes:
• an increase in the proportion of people with diabetes aged 18
years and older who have at least an annual foot examination
(baseline, 55%; target,75%)
• a decrease in foot ulcers due to diabetes (baseline and target
figures are developmental)
• a decrease in lower-extremity amputations due to diabetes
(baseline, 11 cases per 1000; target, 5 cases per 1000 per year).
This objective is based on the estimate that at least 50% of
amputations that occur each year in individuals with diabetes
can be prevented through screening for high-risk patients and
the provision of proper foot care.
The complications of diabetes are particularly devastating to
the foot and often lead to amputation in the absence of early
intervention. In 1997, 67% of hospital discharges for lowerextremity amputation were related to diabetes.7 In addition,
W W W. W O U N D C A R E J O U R N A L . C O M
RISK FACTORS
The following factors associated with the diabetes disease
process put the diabetic foot at risk for ulceration (and, ultimately, amputation):
• absent protective sensation
• vascular insufficiency
• foot deformities that cause areas of high focal pressure
• autonomic neuropathy that causes fissuring of the integument and osseous hyperemia
• limited joint mobility
• obesity
• impaired vision
• poor glucose control that causes advanced glycosylation
• impaired wound healing
• history of foot ulceration
• history of previous lower-extremity amputation.12
Although neuropathy is generally considered the most common complication of diabetes associated with ulceration, biomechanical instability and resulting deformities are usually
present in patients with serious ulceration. Foot deformities are
often unrecognized and inadequate protective footwear fre69
ADVANCES IN SKIN & WOUND CARE • MARCH/APRIL 2003
quently causes tissue irritation and breakdown. Physical
assessment of a patient with diabetes should be approached
with an understanding that every diabetic foot is unique and
requires treatment that is modified according to the presence
of these risk factors.
PHYSICAL EXAMINATION
HISTORY TAKING
Dermatologic examination
Before examining a patient’s lower extremity, the practitioner
should obtain a detailed history and perform a general physical examination. The complete patient history consists of the
medical, family, and social histories.
The medical history should include all medical conditions
that have been and are presently being treated. Patient care
should be documented across the continuum of care, from the
first practitioner to see the patient (usually the primary care
physician) to the specialist. Verify and document care at each
visit,including any changes in the patient’s treatment plan.The
duration and course of the disease should be noted, including
new complications that have developed, such as renal, ophthalmologic, or neurologic problems. Record the method that
the patient uses to monitor his or her blood glucose level,along
with the patient’s last blood glucose and hemoglobin A1c
(HbA1c) levels.All medications, dosages, and patient allergies
should also be documented. A detailed chronologic history of
the presenting complaint should then be obtained.
A careful family history should be obtained,noting if any relatives have diabetes or have suffered from complications of the
disease, such as eye or kidney disease, ulceration, or amputation.
Discuss social issues,such as tobacco,alcohol,or illegal drug
use, with the patient. Professional counseling may be required
to help patients minimize the use of harmful substances.
Tobacco use has a devastating affect on the circulation and
should be avoided. Alcohol use markedly elevates the blood
glucose level and hastens the development of diabetic neuropathy.
Some attempt should be made to evaluate each individual’s
living situation, including the amount of family support available to the patient. A simple test of a patient’s level of adherence is to assess whether they have taken the time to purchase
a glucose meter and use it to test their blood glucose levels on
a regular basis. Patients who know their daily blood glucose
levels and have some idea of their HbA1c values are generally
more adherent.
Finally, perform a detailed review of body systems to look for
changes in the patient’s general health and to detect early signs
of complications related to diabetes. A complete report that
specifies the findings and suggested treatments should be sent
to the patient’s primary care physician.
The dermatologic examination should include visual inspection of the skin on the legs and feet, particularly the dorsal,
plantar, medial, lateral, and posterior surfaces. Check behind
the patient’s heel and between the toes and closely examine
each of the toenails, which are frequently overlooked. Note if
the character of skin changes from the more proximal leg to the
more distal foot. Compare the skin on the feet to the skin on
the arms and hands. Record any changes in color, pigmentation, texture, and turgor. The presence of calluses and their
location, size, and color should be documented because they
may indicate areas of mechanical stress or preulcer formation.
Pigmentation in a specific area or over a diffuse area may indicate abnormalities, such as hemosiderin deposition related to
venous or arterial insufficiency, chronic inflammatory conditions, or malignancy.
The texture of the skin is also an important indicator of the
general health of the patient. Scaly skin may indicate a lack of
hydration, anhydrosis secondary to diabetes, or a tinea infection. Skin turgor is the skin’s degree of resistance to deformation and is used to assess the degree of fluid loss. To measure
turgor, tent the skin between 2 fingers, then release. Skin with
normal turgor rapidly returns to its normal position. Skin with
decreased turgor remains elevated. Accumulation of fluid in
the tissue increases skin turgor and may be due to an edematous, infective, or traumatic process.13
Other important observations include the presence of peeling
skin and maceration or fissuring of the interdigital skin. Inspect
the toenails for length, color, thickness, presence of subungal
debris,odor, separation from the nail bed, and pain. The overall
appearance of the nails is a good indicator of how much attention a patient pays to his or her overall foot health. Fissures on
the heel or ball of the foot may lead to ulceration and should be
treated with debridement and appropriate dressings.
Debride calluses to reduce pressure on underlying structures14 and determine the cause of the lesion. Biomechanical
control and off-loading of the callused area should be provided to reduce risk of skin breakdown and reoccurrence. Plantar
calluses may be preulcerative and should be followed at regular intervals for debridement and off-loading as needed.
Three common skin disorders seen in patients with diabetes
are diabetic dermopathy, necrobiosis lipoidica diabeticorum,
and bullous diabeticorum. Diabetic dermopathy is character-
ADVANCES IN SKIN& WOUND CARE • VOL.16 NO. 2
Physical examination of the lower extremity is based on assessment of the dermatologic, vascular, neurologic, and musculoskeletal systems (see Annual Comprehensive Diabetes Foot
Exam Form on-line at http://www.woundcarejournal.com).
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ized by round, reddish-brown papules found along the lower
leg. Necrobiosis lipoidica diabeticorum presents with slowly
enlarging, irregular, hyperpigmented plaques on the shins.
Both are usually asymptomatic,generally resolve on their own,
and may reappear spontaneously. Treatment for this disorder is
difficult. Topical and intralesional steroids have been shown to
reduce the duration and severity of the lesions. The disease
goes through periods of exacerbation and remission with no
known triggers to alert the practitioner to when the condition
will flare up. Other treatments that have been shown to help
include 1 daily aspirin, pentoxifylline, dipyridamole, and ultraviolet light.
Bullous diabeticorum presents as asymptomatic fluid-filled bullae found on the upper and lower extremities, which may be the
result of vasculopathy.Treatment is not necessary unless the lesions
break, then topical antibiotics or drying agents can be used.15
Document any other dermatologic complaint and obtain a
consultation with a podiatrist or dermatologist for overall care,
if necessary.
Vascular examination
Patients with diabetes should be considered at risk for peripheral vascular disease until proven otherwise. Initially, the practitioner should palpate for pulses bilaterally in the dorsalis
pedis, posterior tibial, popliteal, and superficial femoral arteries.A commonly accepted grading system for pulse strength is:
0 = nonpalpable; 1 = weak,but present; 2 = normal; 3 = strong;
and 4 = bounding.
Assess skin temperature using the back of the hand.Normal
skin temperature ranges from warm at the tibia to cool at the
distal toes. Many patients with diabetes, however, have no
change in palpable temperature due to distal vasodilation
FOOT CARE TIPS: Pointers to share with patients and their caregivers
1. Take care of your diabetes.
• Work with your health care team to keep your blood sugar within a good range.
2. Check your feet every day.
• Look at your bare feet every day for cuts, blisters, red spots,
and swelling.
• Use a mirror to check the bottoms of your feet or ask a family
member for help if you have trouble seeing.
3. Wash your feet every day.
• Wash your feet in warm, not hot, water every day.
• Dry your feet well. Be sure to dry between the toes.
4. Keep the skin soft and smooth.
• Rub a thin coat of skin lotion over the tops and bottoms of your
feet, but not between your toes.
5. Smooth corns and calluses gently.
• If your feet are at low risk for problems, use a pumice stone to
smooth corns and calluses. Don’t use over-the-counter products
or sharp objects on corns or calluses.
6. If you can see and reach your toenails, trim them each
week or when needed.
• Trim your toenails straight across and file the edges with an
emery board or nail file.
7. Wear shoes and socks at all times.
• Never walk barefoot.
• Wear comfortable shoes that fit well and protect your feet.
• Feel inside your shoes each time you put them on to make sure
the lining is smooth and that there are no objects inside.
8. Protect you feet from hot and cold.
• Wear shoes at the beach or on hot pavement.
• Wear clean socks at night if your feet get cold.
• Don’t test bath water with your feet.
• Don’t use hot water bottles or heating pads.
9. Keep the blood flowing to your feet.
• Put your feet up when sitting.
• Wiggle your toes and move your ankles up and down for 5 minutes, 2 or 3 times a day.
• Don’t cross your legs for long periods of time.
• Don’t smoke.
10. Be more active.
• Plan your physical activity program with your doctor.
11. Check with your health care provider.
• Have your health care provider check your bare feet and find
out whether you are likely to have serious foot problems.
Remember that you may not feel the pain of an injury.
• Call your health care provider right away if you find a cut, sore,
blister, or bruise on your foot that does not begin to heal after
one day.
• Follow your health care provider’s advice about foot care.
12. Get started now.
• Begin taking good care of your feet today.
• Set a time every day to check your feet.
Source: National Diabetes Education Program. Feet Can Last a Lifetime. A Health Care Provider’s Guide to Preventing Diabetes Foot Problems. Bethesda, MD: National Institute of
Diabetes and Digestive and Kidney Diseases and National Institutes of Health, November 2000. On-line at http://www.ndep.nih.gov/materials/pubs/feet/feet.htm.
W W W. W O U N D C A R E J O U R N A L . C O M
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related to autonomic neuropathy. Controlling their blood glucose levels, exercise, and a proper diet may help improve the
circulatory status of patients with early mild disease.
Subpapillary venous plexus filling time should be assessed by
pressing the distal pulp of a toe until it blanches, then counting
the number of seconds it takes to return to a normal color.
Normal reperfusion takes from 0 to 3 seconds. Immediate refill
may be an indication of capillary atony associated with autonomic neuropathy; delayed refill is an indication of arterial
ischemia. The absence of hair on the feet and digits may indicate inadequate circulation; however, the absence of hair is not
a final indicator of vascular status. Examine the patient for
edema in the ankle and/or foot, which may be pitting (soft fluid)
or brawny (hard) due to venous insufficiency, lymphatic insufficiency, hypertension, or heart failure. Check for the presence of
varicose veins, hemosiderosis (brown staining of the ankle
area), and scarring from previous ulceration. Arterial insufficiency should be suspected when the patient experiences pain
in the calf or foot on activity, which is relieved with rest (intermittent claudication).
Noninvasive tests for arterial insufficiency can be performed
in the office setting, including calculation of the ankle-brachial
index (ABI) and toe-brachial index (TBI). Calculate the ABI by
taking the systolic blood pressure at the ankle and dividing it by
the systolic pressure of the arm (both are measured by a
Doppler). A normal ABI ranges from 0.9 to 1, moderate arterial
disease from 0.75 to 0.89, severe arterial disease from 0.5 to 0.74,
and limb-threatening total occlusion is below 0.5. However, ABI
results can be misleading and should be used with caution in
patients with diabetes, who may have elevated ankle pressures
due to calcified vessel walls.14 Because digital pressures may be
more reliable for these patients, the TBI should be used. A hallux digital pressure is considered normal at 50 mm Hg; values of
30 mm Hg or lower are indicative of a significant decease in
peripheral perfusion.
Other noninvasive tests may be used to help confirm
ischemia. Pulse-volume recordings (PVRs) measure blood pressure along the lower extremity and quantify the change in size
and shape of the waveform produced.16 Segmental pressure
tests with TBI may be combined with PVRs or used alone to
determine ischemia. In addition, duplex B-scan ultrasonography
of the lower limb allows for noninvasive quantitative assessment
of blood flow and identification of areas with occlusion. The use
of duplex ultrasonography has increased because its sensitivity
and specificity rate is greater than 90%.17
Although noninvasive vascular studies are useful general
screening tools, they are not as reliable as invasive studies to
determine the location and extent of occlusive disease.
Coordinated care with an interventional radiologist and a vascuADVANCES IN SKIN& WOUND CARE • VOL.16 NO. 2
lar specialist is an integral component of caring for the patient
with diabetes.18 For example, magnetic resonance angiography
(MRA) can be performed after injecting contrast media into the
arterial tree. Specific areas of occlusion can then be easily identified, although the extent of the occlusion may be difficult to
ascertain.Arteriograms are the standard of care for many facilities and newer techniques that utilize digital subtraction angiography provide enhanced contrast.
Neurologic examination
Deep tendon reflexes,light touch,2-point discrimination,pain,
and sharp/dull sensations may be diminished or absent in the
diabetic foot. In fact, the absence of protective sensation is the
single most important risk factor in the development of a foot
ulcer.19
To determine the degree of diabetic neuropathy, assess
vibratory sensation with a tuning fork or a biothesiometer
(Biomedical Instrument Corporation, Newbury, OH) or perform a quantitative assessment of light touch using a SemmesWeinstein monofilament.
Vibratory sensation is usually tested with a 128 Hz cycle tuning fork, which is placed on the medial eminence of the first
and fifth metatarsophalangeal joints, the base of the fifth
metatarsal, the navicular, and the medial and lateral malleoli.
The patient tells the practitioner when the vibration ceases and
a subjective evaluation of the degree of sensory loss is made
based on comparisons with the opposite, uninvolved limb or
the patient’s hand.20
A more accurate test of vibration is performed using a biothesiometer, which is operated by placing the testing head over
a bony prominence and slowly increasing the vibratory wave.
Patients without diminished sensation can feel vibrations at 25
volts or less. A vibratory perception threshold of 25 volts or
more is indicative of peripheral neuropathy.21
A more commonly utilized and less expensive method of
testing for the absence of protective sensation is use of the
Semmes-Weinstein 5.07 (10 gram) monofilament (see Assessing
Protective Sensation with a Monofilament). The monofilament is
applied at various locations on the foot, pressed until the filament bends halfway, and then released. The practitioner should
apply the monofilament at several locations on the foot.
Different studies have suggested sampling 5, 8, or 10 sites. It is
the authors’ recommendation that the original 10 sites designated by the Carville Center be examined. These sites are the
pulp of the first, third, and fifth digits; the plantar aspect of the
first, third, and fifth metatarsophalangeal joints; the plantar
medial arch (navicular) and the plantar lateral midfoot (cuboid);
the plantar central heel; and the dorsal first web space. If the
patient is unable to perceive the filament at 1 or more of the
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ASSESSING PROTECTIVE SENSATION WITH A MONFILAMENT
A Semmes-Weinstein monofilament is commonly used to assess protective sensation in the feet of patients with diabetes. The 5.07
(10 gram) monofilament wire is applied to each foot at 10 sites—the pulp of the first, third, and fifth digits; the plantar aspect of the
first, third, and fifth metatarsophalangeal joints; the plantar medial arch (navicular) and the plantar lateral midfoot (cuboid); the plantar
central heel; and the dorsal first web space. Loss of protective sensation generally is indicated by a patient’s inability to feel the
monofilament at 1 or more of 10 sites. The following pointers should assist in ensuring that the procedure is done correctly:
1. Place the patient in a supine or sitting position. His or her legs should be supported and shoes and socks should be removed.
Touch the monofilament to the patient’s arm or hand to demonstrate what it feels like. During the test, the patient should respond
“yes” each time the pressure of the monofilament is felt
on the foot.
2. Make sure the patient’s feet are in a neutral position,
with toes pointing straight up. The patient should then
close his or her eyes so that the test can begin. Hold the
monofilament perpendicular to the foot, press it against
the first site, increasing the pressure until the monofilament wire bends into a C-shape. Make sure it does not
slide over the skin. The device should be held in place for
about 1 second. After the patient responds, record the
response on a foot screening form. A “+” should be used
for a positive response and a “-” for a negative response.
Then move to the next site.
3. Remember to test sites in random order and to vary
the time between applications. That way, the patient will
not be able to guess the correct response. If the patient
has an ulcer, scar, callus, or necrotic tissue at the test
site, apply the monofilament along the perimeter of the
abnormality, not directly on it.
4. Refer the patient for an intensive education and follow-up program to learn how to inspect and protect the feet if the test indicates
he or she is experiencing loss of protective sensation. The patient can be taught self-assessment with the monofilament, but it does
not replace a professional evaluation.
From: Sloan HL, Abel RJ. Getting in touch with impaired foot sensitivity. Nursing98 1998;28(11):50-1.
sites tested, the diagnosis of loss of protective sensation (LOPS)
is made.22
LOPS has been correlated with a risk of ulceration,especially in biomechanically unbalanced feet with secondary bony
prominences, such as bunions or hammer toes. Patients with
LOPS are unable to feel tight socks or shoes,foreign objects in
the shoe,or even a puncture from a sharp object.Because these
patients do not feel pain, they may continue to walk on small
ulcers that enlarge and deepen, increasing the risk of deep
space infection or osteomyelitis.
A thorough mechanical examination of the patient should
be performed,including an assessment of foot type,charting of
deformities,and range of motion and muscle strength.No biomechanical assessment is complete without checking the
patient’s shoes for appropriateness and wear and examining
any orthotic devices (see Footwear Basics). Inadequate footwear
frequently causes ulceration,and the patient should be referred
to a pedorthist, if necessary.
Feet can be classified as flat or pronated, rectus or straight,
and cavus or high-arched. Although ulcers occur in patients
with neuropathy and rectus feet,they are more common in the
other 2 foot types.
If the foot is flexible, orthotics designed to correct the
pronated position may help unload the forefoot and reduce
compensatory digital deformities. Fixed rigid deformities
should be accommodated with total contact orthosis and depth
footwear. Equinus secondary to glycosylation of connective tis-
Musculoskeletal examination
Deformity secondary to altered biomechanics of the foot is
another significant risk factor for the diabetic foot,especially in
the presence of neuropathy. LOPS alone without deformity
may result in the development of an ulcer, but ulceration is
more likely when these factors are combined.
W W W. W O U N D C A R E J O U R N A L . C O M
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ADVANCES IN SKIN & WOUND CARE • MARCH/APRIL 2003
sue and mechanical adaptation can exacerbate hyperpronation
of the foot and increase forefoot pressures in stance and gait.
Pronation leads to increased pressure on the medial column of
the foot that can result in the development of a pressure ulcer
under the first metatarsal head.Digital contractures due to biomechanical imbalance and exacerbated by motor neuropathy
lead to increased pressure on the dorsum of the toes and the
plantar metatarsal heads. Hyperkeratoses, blisters, and ulcerations may occur at these sites of irritation.
Most pathomechanic abnormalities in the foot will lead to
future irritation and increase the risk of ulceration.
Biomechanical imbalance can be treated with custom-made
orthotic inserts and specialized footwear. For more severe
problems,such as open ulcerations or Charcot deformity, additional off-loading may be accomplished with bracing and custom footwear. Appropriate types of off-loading techniques and
bracing may require consultation with a podiatrist, pedorthist,
or an orthotist.
Patients with diabetes who have foot ulcerations can be
referred to a podiatrist for debridement, wound care, specialized off-loading devices, or corrective surgery. Specific offloading devices may include healing sandals, removable prefabricated walking casts,wedged or half-shoes,or total contact
casting.
SURGICAL CONSIDERATIONS
Patients with rigid deformities who are at significant risk for
ulceration or who have a history of a previous ulcer may be
candidates for elective foot surgery. Minor deformities can be
addressed with relatively simple procedures. Patients with significant deformities or Charcot arthropathy may require more
extensive reconstructive surgical procedures. Patients with
well-controlled diabetes who are adherent with treatment
generally experience few postoperative complications.
FOOTWEAR BASICS
Whether a patient with diabetes is using the appropriate
footwear will depend on the degree of risk for ulceration
and/or the presence of active or recently healed ulceration.
Patients who lack protective sensation and who have a history
of foot deformity, ulceration, or amputation of any part of the
foot should be referred to a podiatrist for an evaluation for
special shoes or orthotics.
Patients who still have protective sensation and no history
of foot deformity or ulceration generally do not need custom
shoes. There are criteria for appropriate footwear, however,
that will help to ensure that the patient remains ulcer-free. For
a proper shoe fit, the person should be standing when measured for shoes. The ball of the foot (metatarsal head) should
correspond to the widest part of the shoe. The shoe must not
cause discomfort or skin irritation; shoe-related repetitive pressure has been associated with ulceration.
The following are characteristics of ideal footwear for any
person with diabetes:
• Laced shoes offer maximum adjustability.
• Calfskin offers flexibility and breathability.
• Secure-fitting heels avoid friction.
• Wedged soles offer greater support than a separate heel and
toe.
• Cushioned crepe soles provide traction and comfort.
• Heels should not be higher than 1 inch.
• Pointed-toe shoes should be avoided; a wide toe box is
best.
• Maintain 1⁄2 inch between the longest toe and the end of the
shoe.
• The shoe should bend easily at the ball of the foot.
• The shoe should have adequate arch support.
It is best to consult with a specialist, such as a pedorthist
or a podiatrist, before making a recommendation.
CONCLUSION
Proper physical assessment of the patient with diabetes at risk
for foot ulceration, infection, or amputation may lead to prevention of lower-extremity complications and early intervention of identified pathology. Although practitioners routinely
discover these problems during office visits, family members
and other medical personnel can be trained to look for signs of
diabetic foot pathology and can help an individual seek immediate attention for problems (see Foot Care Tips). A team
approach, comprised of the patient’s primary care physician,
endocrinologist, vascular surgeon, cardiologist, ophthalmologist, dermatologist, diabetic educator, and dietitian, greatly
benefits the patient with diabetes and has been shown to help
patients avoid preventable complications caused by the disease.23 ●
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Review. Washington,DC:Government Printing Office; 2000.
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From: Umeh L, Wallhagen M, Nicoloff N. Identifying diabetic patients at high risk for
amputation. Nurse Practitioner 1999;24(8):56, 60, 63-6, 69-70.
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W W W. W O U N D C A R E J O U R N A L . C O M
Understanding and Improving Health.Washington,DC:Government Printing Office,2000.
7. Centers for Disease Control and Prevention. Hospital discharge rates for nontraumatic
lower extremity amputation by diabetes status—United States, 1997. MMWR
2001;50(43):954-8.
8. Dinh T, Pham H, Veves A. Emerging treatments in diabetic wound care. Wounds
2002;14(1):2-10.
9. National Hospital Discharge Survey, 1996.Centers for Disease Control and Prevention,
National Center for Health Statistics,Division of Health Care Statistics.Data Computed
by the Division of Diabetes Translation,National Center for Chronic Disease Prevention
and Health Promotion.
10. Levin, ME. Preventing amputation in the patient with diabetes. Diabetes Care
1995;18:1383-94.
11. Apelqvist J,Ragnarson-Tennvall G,Larsson J, Persson U.Long-term costs for foot ulcers
in diabetic patients in a multidisciplinary setting. Foot Ankle Int 1995;16:388-94.
12. Boyko EJ,Ahroni JH,Stensel V, Forsberg RC,Davignon DR,Smith DG.A prospective study
of risk factors for diabetic foot ulcer. The Seattle Diabetic Foot Study. Diabetes Care
1999,22:1036-42.
13. Jelinek JE. Dermatology. In: Marvin EL, O’Neal LW, Bowker JH. The Diabetic Foot. St.
Louis,MO:Mosby-Yearbook; 1993.
14. Hoffman,AF. Evaluation of arterial blood flow in the lower extremity. Clin Podiatr Med
Surg 1992;9(1):19-56.
15. McNeely MJ,Boyko E,Ahroni JH,et al.The independent contributions of diabetic neu-
CONTINUING MEDICAL EDUCATION
INFORMATION FOR PHYSICIANS
Lippincott Williams & Wilkins is accredited by
the Accreditation Council for Continuing
Medical Education to provide continuing med ical education for physicians.
Lippincott Williams & Wilkins designates this
educational activity for a maximum of 1 category 1 credit toward the AMA Physician’s
Recognition Award. Each physician should
claim only those credits that he/she actually
spent in the activity.
CONTINUING-EDUCATION
INFORMATION FOR NURSES
This continuing nursing education (CNE) activity
for 3.0 contact hours is provided by Lippincott
Williams & Wilkins, which is accredited as a
provider of continuing education in nursing by the
American Nurses Credentialing Center’s
Commission on Accreditation and by the
American Association of Critical Care Nurses
(AACN 9722 Category O). This activity is also
provider-approved by the California Board of
Registered Nursing, provider number CEP11749,
for 3.0 contact hours. Lippincott Williams &
16.
17.
18.
19.
20.
21.
22.
23.
ropathy and vasculopathy in foot ulceration: how great are the risks? Diabetes Care
1995;18:216-9.
Whelan JF, Barry JH, Moir, JD. Color flow Doppler ultrasonography: comparison with
peripheral arteriography for the investigation of peripheral vascular disease. J Clin
Ultrasound 1992;20:369-74.
Eze AR,Comerota AJ,Cisek P, Holland BS,Kerr RP, Veeramasuneni R,Comerota AJ,Jr.
Intermittent calf and foot compression increases lower extremity blood flow. Am J Surg
1996;172:130-5.
Thivolet C,el Farkh J, Petiot A,Simonet C, Tourniaire J.Measuring vibration sensations
with graduated tuning fork.Simple and reliable means to detect diabetic patients at risk
of neuropathic foot ulceration.Diabetes Care 1990;13:1077-80.
Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Korchmer AW. Assessment and
management of foot disease in patients with diabetes.N Engl J Med 1994;13:854-60.
Bloom S, Till S,Sonksen P, Smith S.Use of a biothesiometer to measure individual vibra tion thresholds and their variation in 519 non-diabetic subjects. Br Med J
1984;288:1793-5.
Fernando DJ,Masson EA, Veves A,Boulton AJM.Limited joint mobility:relationships to
neuropathic ulceration.Diabetes Med 1992;5:333-7.
Birke JA, Sims DS. Plantar sensory threshold in the ulcerative foot. Lepr Rev
1986;57:261-7.
Holstein PE, Sorenson S. Limb salvage experience in a multidisciplinary diabetic foot
unit.Diabetes Care 1999:22 (suppl 2):97-103.
Wilkins is also an approved provider of nursing
continuing education in Alabama, Florida, and
Iowa and holds the following provider numbers:
AL #ABNPO114; FL #FBN2454; IA #75. All of its
home study activities are classified for Texas nursing continuing-education requirements as Type 1.
CONTINUING-EDUCATION
INSTRUCTIONS
To earn continuing medical education (CME) or
continuing-education (CE) credit, follow these
instructions:
1. Read the article on pages 68-75. Choose
one answer for each question and darken circle.
2. Fill in registration information and evaluation on answer form (Social Security or license
number must be included to process test).
3. Mail your answer form (copies accepted)
and processing fee ($19.95 for nurses, $20.00 for
physicians) to: Lippincott Williams & Wilkins
(LWW), 2710 Yorktowne Blvd, Brick, NJ 08723.
Make check payable to Lippincott Williams &
Wilkins; if paying by credit card, include number
and expiration date. Within 4 weeks, you will be
notified of your test results.
4. Nurses may fax the test (credit card
orders only) to 732-255-2926, and we’ll fax
back your CE certificate within two business
days. Provide a fax number for a location where
confidential information will be safe
(home/workplace). Faxes sent to a workplace
will be accompanied by a cover letter. LWW is
not responsible for faxes not received due to a
malfunctioning machine on the receiving end. A
CE certificate will be mailed after attempts to
fax have failed.
5. Nurses may take the test on-line at
http://www.nursingcenter.com/prodev/
ce_online.asp and have it processed immediately.
The passing score for tests is 70%. If you
pass, a certificate for earned contact hours
will be awarded by Lippincott Williams &
Wilkins. You will also receive an answer sheet
with the rationale for each correct answer.
Nurses who fail the test can take the test
again for free. Only the first entry sent by
physicians will be considered for credit.
For questions about test results, contact
Lippincott Williams & Wilkins, CE Dept, 345
Hudson St., New York, NY 10014; 1-800-9336525, ext. 332.
*In accordance with the Iowa Board of Nursing administrative rules governing grievances, a copy of your evaluation of the CE offering may be submitted directly to the Iowa Board of Nursing.
W W W. W O U N D C A R E J O U R N A L . C O M
75
ADVANCES IN SKIN & WOUND CARE • MARCH/APRIL 2003
Physical Assessment of the Diabetic Foot
Steven R. Kravitz, DPM, FACFAS, FAPWCA; James McGuire, DPM, PT, FACFAS,
FAPWCA; and Sean D. Shanahan, DPM, MPH
C M E
C AT E G ORY 1
1 Hour
A NC C / AA CN
3.0 Contact Hours
PURPOSE: To provide physicians and nurses with an overview of diabetic foot assessment.
TARGET AUDIENCE: This continuing-education activity is intended for physicians and nurses with an interest in learning about proper
diabetic foot assessment.
OBJECTIVES: After reading the article and taking the test, the participant will be able to: 1. Review the epidemiology of diabetes, diabetic foot ulcers, and lower-extremity amputation related to diabetes. 2. Identify risk factors for foot ulceration in patients with diabetes.
3. Identify normal and abnormal findings in the dermatologic, vascular, neurologic, and musculoskeletal assessment of the foot in patients
with diabetes.
1. The sixth leading cause of death in the
United States, diabetes affects
a. 16 million Americans, 4.9 million of them
undiagnosed.
b. 16 million Americans, 6.5% of the population.
c. 17 million Americans, 5.9 million of them
undiagnosed.
d. 17 million Americans, 4.9% of the population.
2. Diabetic dermopathy is characterized by
a. slowly enlarging, irregular, hyperpigmented
plaques on the shins.
b. asymptomatic fluid-filled bullae found on
the upper and lower extremities.
c. reddish-brown papules found along the
lower leg.
d. peeling and maceration or fissuring of the
interdigital skin.
3. Hallux digital pressure is considered
normal at
a. 20 mm Hg.
c. 40 mm Hg.
b. 30 mm Hg.
d. 50 mm Hg.
4. Diabetes is damaging to the afferent
neurobiology of the peripheral neurovascular system, often resulting in
a. loss of protective sensation.
b. increased vascular perfusion of the lower
extremity.
c. increased oxygenation to the foot.
d. nutritional deficiencies.
5. Ulceration is more common in patients
whose feet are classified as either
a. flat or straight.
b. rectus or cavus.
c. pronated or cavus.
d. flat or high-arched.
6. Which of the following statements is
correct?
a. Segmental pressure tests with toe pressure
index may be combined with pulse-volume
recordings or used alone to determine
ischemia.
b. ABI results are the gold standard in diagnosing arterial disease in patients with diabetes.
c. ABIs measure blood pressure along the
lower extremity and quantify the change in
size and shape of the waveform produced.
d. Noninvasive screening tools are as reliable
as invasive studies to determine the loca-
tion and extent of occlusive disease.
7. Which Healthy People 2000 objective
was renewed for Healthy People 2010?
a. Decrease lower-extremity amputations due
to diabetes to 11 cases per 1000 people
per year.
b. Reduce the incidence of diabetes to 2.5
cases per 1000 people and reduce the
prevalence to 25 cases per 1000 people.
c. Increase the proportion of people with diabetes aged 18 years and older who have
at least an annual foot exam from 25% to
55%.
d. Decrease foot ulcers due to diabetes to 5
cases per 1000 per year.
8. Necrobiosis lipoidica diabeticorum is
characterized by
a. slowly enlarging, irregular, hyperpigmented
plaques on the shins.
b. asymptomatic fluid-filled bullae found on
the upper and lower extremities.
c. reddish-brown papules found along the
lower leg.
d. peeling and maceration or fissuring of the
interdigital skin.
9. Patients with pathomechanic abnormalities
a. generally cannot be adequately treated
with orthotics and footwear.
b. may develop hyperkeratoses, blisters, and
ulcerations at sites of irritation.
c. typically do not develop ulcers under the
first metatarsal head.
d. are at greater risk of ulceration than
patients with neuropathy.
10. What is the most important diabetesrelated risk factor in the development of a
foot ulcer?
a. absent protective sensation
b. history of foot ulceration
c. poor glucose control
d. foot deformities
11. In 1997, the percentage of hospital discharges for diabetes-related lowerextremity amputation was
a. 37%.
c. 67%.
b. 45%.
d. 85%.
12. To reduce the risk of developing a foot
ulcer, patients with diabetes should be
advised to
a. wash their feet with hot water every day.
b. rub a thin coat of skin lotion over the tops
and bottoms of their feet and in between
their toes.
c. use hot water bottles or heating pads if
their feet are cold at night.
d. wiggle their toes and move their ankles up
and down for 5 minutes, 2 or 3 times a
day.
13. When palpating for pulses in the dorsalis pedis, a value of 3 indicates that
pulse strength is
a. weak.
c. strong.
b. normal.
d. bounding.
14. The degree of diabetic neuropathy can
be assessed using
a. pulse-volume recording.
b. the ankle-brachial index.
c. magnetic resonance angiography.
d. a tuning fork or biothesiometer.
15. Skin turgor is used to assess
a. the pigmentation of the skin.
b. the degree of fluid loss.
c. the areas of mechanical stress.
d. the skin’s temperature.
16. Bullous diabeticorum is characterized
by
a. slowly enlarging, irregular, hyperpigmented
plaques on the shins.
b. asymptomatic fluid-filled bullae found on
the upper and lower extremities.
c. reddish-brown papules found along the
lower leg.
d. peeling and maceration or fissuring of the
interdigital skin.
17. To obtain a proper shoe fit for a patient
with diabetes,
a. the patient should be sitting when measured for shoes.
b. always refer the patient to a pedorthist,
even if the patient has no history of foot
deformity or ulceration.
c. the metatarsal head should correspond to
the widest part of the shoe.
d. the patient’s height and weight should be
taken into consideration.
18. Immediate refill of the subpapillary
venous plexus may indicate
a. lymphatic insufficiency.
b. inadequate circulation.
c. arterial ischemia.
d. capillary atony associated with autonomic
neuropathy.
19. Which statement about use of the
Semmes-Weinstein monofilament is correct?
a. Press the filament until it bends halfway,
then hold for 10 seconds before releasing.
b. Studies suggest that 5, 8, or 10 sites can
be tested for loss of protective sensation.
c. Loss of protective sensation is diagnosed
when the patient is unable to perceive the
filament at 3 or more sites.
d. The Carville Center recommends testing
only at the pulp of the third digit, the plantar aspect of the fifth metatarsophalangeal
joint, the plantar medial arch, the plantar
central heel, and the dorsal first web
space.
20. Pigmentation over a diffuse area may
indicate an abnormality such as
a. hemosiderin deposition.
b. mechanical stress.
c. preulcer formation
d. anhydrosis.
✂
21. Ideal footwear for a patient with diabetes
a. should not have a wedged sole.
b. should have a heel no higher than 1 inch.
c. should not have a crepe sole.
d. should be a slip-on rather than a lace-up
style.
24. When using a Semmes-Weinstein
monofilament to assess the protective
sensation in the foot of a patient with diabetes,
a. it is acceptable to apply the filament to calluses.
b. hold the filament perpendicular to the foot,
increasing and maintaining pressure for
about 10 seconds.
c. test sites in a set order, but vary the time
between applications.
d. make sure the patient’s feet are in a neutral
position, with toes pointing straight up.
22. An ankle-brachial index (ABI) of 0.62
indicates
a. moderate arterial disease.
b. severe arterial disease.
c. limb-threatening arterial disease.
d. the absence of arterial disease.
23. Patients with loss of protective sensation
a. generally are not at risk for ulceration
unless they also have a deformity secondary to altered biomechanics of the foot.
b. cannot feel tight socks or shoes but can
feel a puncture from a sharp object.
c. will eventually feel an ulcer as it enlarges
and deepens and will seek medical attention.
d. are at increased risk for deep space infection or osteomyelitis.
ANSWER SHEET AND EVALUATION FORM
Please indicate for which discipline you are requesting continuing-education credit:
● Physician (MD and DO only)
● Nurse
Your evaluation of this CME/CE activity will help guide future planning.
1. Did the content of this activity meet the stated learning objectives?
● Yes ● No
2.Did the objectives relate to the purpose of this activity?
(highest) ● 5 ● 4 ● 3 ● 2 ● 1 (lowest)
25. Which of the following statements is
correct?
a. Footwear is not a factor in tissue irritation
and breakdown in a patient with diabetes.
b. Taken together, limited joint mobility, adequate blood glucose, and arterial insufficiency put a diabetic patient at risk for
ulceration.
c. Foot deformities are usually present in
patients with serious ulceration.
d. A history of lower-extremity amputation is
not an issue when assessing a diabetic
patient’s risk for ulceration.
C M E
C AT E G ORY 1
1 Hour
A NC C / AA CN
3.0 Contact Hours
5. Did you perceive any evidence of bias for or against any commercial
products? If yes,please explain.
● Yes ________________________________________________________________
● No
3.How do you rank the overall quality of this educational activity?
(highest) ● 5 ● 4 ● 3 ● 2 ● 1 (lowest)
6. Please state 1 or 2 topics that you would like to see addressed in
future issues.
4.As a result of meeting the learning objectives of this educational
activity, will you be changing your practice behavior in a manner
that improves your patient care?
● Yes ________________________________________________________________
__________________________________________________________________________
● No
__________________________________________________________________________
7. It took ____(hrs) ____(mins) to read and review the article and take the
test.
Physical Assessment
of the Diabetic Foot
Name _____
Address _________________________________________________________________________________________________________________________________
City ___________________________________________________________________________________ State _________________ ZIP _________________
Social Security No. ________________ - __________ - ________________
Medical License No(s) and State(s) of Licensure _________________________________________________________________________
Nursing License No(s) and State(s) of Licensure ________________________________________________________________________
(One of the above numbers is required in order to process this test)
Phone Number (home) ________________________________________________ (work) _______________________________________________
Fax Number (home)___________________________________________________ (work) _________________________________________________
● Visa
● MasterCard
No. _________________________________________ Exp. Date ________________
Any licensed nurse may submit this evaluation form directly to the Iowa Board of Nursing.
Before April 30, 2004, photocopy this form (an original is not necessary) and mail to: Lippincott
Williams & Wilkins, 2710 Yorktowne Blvd, Brick, NJ 08723. Mail your test with a check for $20
(physicians) or $19.95 (nurses),payable in U.S. funds only, to Lippincott Williams & Wilkins.
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A023