Diabetic foot physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2] Vishnu Vardhan Serla M.B.B.S. [3]

Overview

Patients with diabetic foot ulcer could appear ill if ulcers are severe or infected. In severe and chronic infected ulcers patients may have fever, tachycardia and low blood pressure. Neuromuscular examination of patients with diabetic foot is usually normal, except in their foot. Altered motor tone, reflexes and sensation is expected in these patients. Neuropathy symptoms score (NSS) and neuropathy disability score (NDS) are helpful in neuropathy assessment of patients with diabetic foot. Findings such as impaired vibration and pressure perception, position sense and thresholds for warm thermal perception favor the diagnosis of sensory neuropathy. It is critical to check the extremities for findings such as ulcers, peeling skin, dilated or varicose veins, shiny skin with reduced hair distribution and broken nail while examining diabetic foot. Moreover infection possibility should be evaluated. Findings such as pus, erythema, Warmth, induration and bad odor suggest the presence of infection. In some cases unroofing a small scar demonstrates a deeper infected abscesses. In the other word, evaluating an ulcer for infection must be done after debridement. Other necessary physical examinations in these patients are checking the capillary filling time, ankle brachial index, tactile and vibration sensation and pressure perception.

Physical Examination

Appearance of the Patient

• Patients with diabetic foot ulcer could appear ill if ulcers are severe or infected.

Vital Signs

• ±Fever (Based on the infection severity can present as high or low grade fever)
• Hypothermia or hyperthermia may be present
• Tachycardia
• Low blood pressure could be seen in septic patients.

Skin

• Skin examination of patients with diabetic foot is usually normal, except for the foot skin.

HEENT

• HEENT examination of patients with diabetic foot is usually normal.

Neck

• Neck examination of patients with diabetic foot is usually normal.

Lungs

• Pulmonary examination of patients with diabetic foot is usually normal.

Heart

• Cardiovascular examination of patients with diabetic foot is usually normal.

Abdomen

• Abdominal examination of patients with diabetic foot is usually normal.

Back

• Back examination of patients with diabetic foot is usually normal.

Genitourinary

• Genitourinary examination of patients with diabetic foot is usually normal.

Neuromuscular

• Neuromuscular examination of patients with diabetic foot is usually normal, except in their foot. Examine their foot for the following:
  • Motor examination
    • Tone
    • Power
    • Reflexes
  • Sensory examination
    • Vibration
    • Joint position sense

Neuropathy Assessment

The Ipswich Touch Test (IpTT) can diagnosis neuropathy. The A clinical practice guideline by the International Working Group on the Diabetic Foot (IWGDF) recommended the (IpTT) as an alternative to the monofilament exam Instructions for the IpTT are:

"lightly touch the tips of the first, third and fifth toes of each foot, for 1–2 s, with the tip of the index finger. They were not to push, prod, tap or poke, because this may elicit a sensation other than light touch. With their eyes closed, the patient was instructed to say yes whenever they felt the touch."

The neuropathy symptoms score (NSS) and neuropathy disability score (NDS) are helpful in physical examination of patients with diabetic foot.. Findings that favor the diagnosis of sensory neuropathy:

• Impaired vibration and pressure perception
• Impaired position sense
• Depressed tendon reflexes
• Dull, crushing or cramp-like pain in the bones of the feet
• Sensory ataxia
• Shortening of the achilles tendon
• Abnormal thresholds for warm thermal perception
• Decreased neurovascular function

Vascular

See also: Peripheral arterial disease screening

• Pulses such as dorsalis pedis and posterior tibial pulses
  • Although even when both dorsalis pedis and posterior tibial pulses are present, low perfusion can not be excluded.
  • Note that dorsalis pedis and posterior tibial pulses are absent in 8% and 3% of normal population, respectively.
• Capillary filling time (venous refilling > 5s)

The Rational Clinical Examination group concluded"

• "The PAD screening score using the hand-held Doppler has the greatest diagnostic accuracy"
  • The Score is:
    • The number of auscultated components (right posterior tibial artery + left posterior tibial artery; range of 0 for none heard to 3 for normal for each artery)
      plus
    • The grade of palpated posterior tibial artery (right posterior tibial artery + left posterior tibial artery; 2 for normal, 1 for palpated but abnormal, 0 for not palpable for each artery)
      plus
    • A history of myocardial infarction (1 for none, 0 for prior myocardial infarction)
  • Interpretation: normal is 10 (combining both feet). A score < 6 increases risk of PAD.

The USPSTF stated:

• "The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for PAD and CVD risk with the ABI in asymptomatic adults. (I statement)."

Extremities

Inspection

The following list is a summary of possible findings in diabetic foot inspection:

• Peeling skin, maceration, fissuring between toes
• Dilated or varicose veins
• Scar
• Sinuses
• Shiny skin
• Decreased hair distribution
• Areas of pigmentation or discoloration
• Ulcers
  • Ulcers in the areas under pressure such as base of the toe or the fifth metatarsus and posterior aspect of heel.
• Brittle or broken nail
• Infection
  • Such as fungal infection
  • Presence of pus (thick, opaque to white or sanguineous secretion) or at least two of the following is indicative of infection:
    • Redness (Erythema)
    • Pain and local tenderness
    • Warmth
    • Delayed wound healing
    • Swelling or induration
    • Bad odor
  • In some cases unroofing a small scar demonstrates a deeper infected abscesses. In the other word, evaluating an ulcer for infection must be done after debridement.
  • The following are some of the findings that indicate a limb threatening infection:
    • Cellulitis extension more than 2 cm from the ulcer's margin
    • Deep abscesses
    • Osteomyelitis
    • Severe ischemia
• Foot deformities such as charcot foot and hammer toe
• Pink skin
  • Even in ischemic settings due to arteriovenous shunting.

Palpation

The following is a list of recommended examinations in a diabetic foot patients:

• Temperature
• Increased temperature could be due to deep vein thrombosis while decreased temperature could be an ischemia presentation.
• Due to arteriovenous shunting the involved area may feel warm even in presence of ischemia.
• Tenderness (squeeze calf muscle and achilles tendon for tenderness)
• Pulses such as dorsalis pedis and posterior tibial pulses
  • Although even when both dorsalis pedis and posterior tibial pulses are present, low perfusion can not be excluded.
  • Note that dorsalis pedis and posterior tibial pulses are absent in 8% and 3% of normal population, respectively.
• Capillary filling time (venous refilling > 5s)
• Muscle strength and tone
• Check ankle brachial index (ABI)
• Pinprick discrimination and tactile sensation test (use a cotton wool to examine)
• Vibration test (use a 128 Hz-tuning fork)
• Pressure perception test (use a 10-gram (5.07) Semmes––Weinstein monofilament)
  • Single most practical method to assess risks for diabetic foot such as neuropathy
• Quantitative sensory testing and autonomic testing
• Probing
  • Using a blunted sterile probe will help physicians to determine ulcer's margins, sinus tract development and involvement of tendons, bones or joints.
  • Positive probe-to-bone is strongly correlated with osteomyelitis.

Video: Physical Examination Diabetes

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Image: Diabetic Foot Ulcer

Diabetic foot ulcer

Staging of diabetic wounds

A systematic review identified better staging systems:

• University of Texas (UT) Score

More recently, the International Working Group’s diabetic foot (IWGDF) risk classification .

International Working Group’s diabetic foot (IWGDF) risk classification

Risk group	Findings
Risk Group 0	No neuropathy No peripheral arterial No foot deformity or limited joint mobility
Risk Group 1	Peripheral neuropathy No peripheral arterial No foot deformity or limited joint mobility
Risk Group 2	Peripheral neuropathy and foot deformity or limited joint mobility and/or peripheral arterial disease
Risk Group 3	History of ulcer or amputation or Charcot

The working group separately describes the UT classification of ulcers. This system includes "preulcerative" lesions:

• "Grade 0 wounds are preulcerative areas or previous ulcer sites that are now completely epithelialized after debridement of hyperkeratosis and nonviable tissue. The diagnosis of a Grade 0 wound can be made only after removal of any regional hyperkeratosis, as quite often frank ulcerations may be hidden by overlying calluses"
• The system adds whether the lesion is associated with infection or ischemia.

References

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