Assessment of Foot Neuropathies: Difference between revisions

No edit summary
No edit summary
 
(27 intermediate revisions by 3 users not shown)
Line 1: Line 1:
<div class="noeditbox">
<div class="editorbox"> '''Original Editor '''- [[User:Stacy Schiurring|Stacy Schiurring]] based on the course by [https://members.physio-pedia.com/instructor/diane-merwarth/ Diane Merwarth]<br>
This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! ({{REVISIONDAY}}/{{REVISIONMONTH}}/{{REVISIONYEAR}})
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}  
</div>
</div>  
== Neuropathy Assessment ==


<div class="editorbox">
Diabetes is the leading cause of peripheral neuropathy worldwide.<ref name=":3">Boulton AJ, Armstrong DG, Albert SF, Frykberg RG, Hellman R, Kirkman MS, Lavery LA, LeMaster JW, Mills Sr JL, Mueller MJ, Sheehan P. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2494620/ Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists]. Diabetes care. 2008 Aug 1;31(8):1679-85.</ref> Peripheral neuropathy can have devastating outcomes, including (1) foot ulcers, (2) major amputation, (3) falls, (4) intracranial injuries, and (5) decreased quality of life. Approximately one in four people with diabetes will develop a diabetic foot ulcer.<ref>Hicks CW, Wang D, Windham BG, Matsushita K, Selvin E. [https://www.nature.com/articles/s41598-021-98565-w Prevalence of peripheral neuropathy defined by monofilament insensitivity in middle-aged and older adults in two US cohorts]. Scientific reports. 2021 Sep 27;11(1):19159.</ref>
'''Original Editor '''- [[User:User Name|User Name]]


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}  &nbsp; 
Neuropathy, foot deformity, and trauma are the most common "triad of causes that interact and ultimately result in ulceration".<ref name=":3" /> Proper assessment and identification of patients at risk for ulcer formation is vital in wound prevention and complication management.<ref name=":3" /> This article provides an overview of a systematic method of foot neuropathy assessment. It also details foot self-care and prevention education.
</div>  
 
== Introduction ==
'''For a review of foot neuropathy types, please see [[Introduction to Foot Neuropathy|this article]]. Please see this [[Wound Care Terminology|article]] for a list of common wound care terminology.'''


== Neuropathy Assessment ==
=== Frequency of Assessment ===
For a review of foot neuropathies, please see [[Introduction to Foot Neuropathy|this article]].
The [https://diabetes.org American Diabetes Association] (ADA) [https://diabetesjournals.org/care/issue/45/Supplement_1 Standards of Medical Care in Diabetes] recommends all patients with diabetes be assessed for diabetic peripheral neuropathy:


Patients with diabetes
* at the time of diagnosis of [[Diabetes Mellitus Type 2|type 2 diabetes mellitus]]
* five years after the diagnosis of [[Diabetes Mellitus Type 1|type 1 diabetes mellitus]]
* and then at least annually for continued reassessment<ref>American Diabetes Association Professional Practice Committee; [https://diabetesjournals.org/care/article/45/Supplement_1/S185/138917/12-Retinopathy-Neuropathy-and-Foot-Care-Standards 12. Retinopathy, Neuropathy, and Foot Care: ''Standards of Medical Care in Diabetes—2022'']. ''Diabetes Care'' 1 January 2022; 45 (Supplement_1): S185–S194.</ref><ref name=":1">Merwarth, D. Understanding the Foot Programme. Assessment of Foot Neuropathies. Physioplus. 2023.</ref>


So as just discussed, there are multiple complications that can develop in an individual with diabetes directly related to one, two, or all three of the neuropathies that I just reviewed. Most of the time, patients with diabetes, especially if they've had it for a long period of time, will have all three of those neuropathies simultaneously, which even increases further their risk of developing a foot ulcer without proper care.
However, depending on a patient's risk for foot ulcer formation, they may need to be reassessed more frequently.<ref name=":1" /> The [https://iwgdfguidelines.org International Working Group on the Diabetic Foot] (IWGDF) developed an evidence-based risk stratification system which provides recommendations on how often more at-risk patients with diabetes should be reassessed. The assignment of risk is based on the presence of:<ref name=":0">Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Fitridge R, Game F, Monteiro‐Soares M, Senneville E, IWGDF Editorial Board. [https://onlinelibrary.wiley.com/doi/pdf/10.1002/dmrr.3657 Practical guidelines on the prevention and management of diabetes‐related foot disease (IWGDF 2023 update)]. Diabetes/Metabolism Research and Reviews. 2023 May 27:e3657.</ref>


=== Frequency of Assessment ===
# lack of protective sensation (LOPS)
The [https://diabetes.org American Diabetes Association] (ADA) [https://diabetesjournals.org/care/issue/45/Supplement_1 Standards of Medical Care in Diabetes] recommends all patients with diabetes be assessed for diabetic peripheral neuropathy at diagnosis of [[Diabetes Mellitus Type 1|Diabetes Mellitus type 2]], 5 years after the diagnosis of [[Diabetes Mellitus type 1]], and then at least annually for continued reassessment.<ref>American Diabetes Association Professional Practice Committee; [https://diabetesjournals.org/care/article/45/Supplement_1/S185/138917/12-Retinopathy-Neuropathy-and-Foot-Care-Standards 12. Retinopathy, Neuropathy, and Foot Care: ''Standards of Medical Care in Diabetes—2022'']. ''Diabetes Care'' 1 January 2022; 45 (Supplement_1): S185–S194.</ref>
# [[Peripheral Arterial Disease|peripheral artery disease]] (PAD)
# foot deformity
# other high-risk diagnoses or procedures (see Table 1 for details)


However, dependent on an individual patient's risk for foot ulcer formation, they may need to be reassessment more frequently.  The [https://iwgdfguidelines.org International Working Group on the Diabetic Foot] (IWGDF) developed an evidence-based risk stratification system which provides recommendations on how often more at risk patients with diabetes should be reassessed.  The assignment of risk is based on the presence of (1) lack of protective sensation (LOPS), (2) [[Peripheral Arterial Disease|Peripheral artery disease]] (PAD), (3) foot deformity, and (4) other high risk diagnoses or procedures.<ref name=":0">Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Fitridge R, Game F, Monteiro‐Soares M, Senneville E, IWGDF Editorial Board. [https://onlinelibrary.wiley.com/doi/pdf/10.1002/dmrr.3657 Practical guidelines on the prevention and management of diabetes‐related foot disease (IWGDF 2023 update)]. Diabetes/Metabolism Research and Reviews. 2023 May 27:e3657.</ref>
{| class="wikitable"
{| class="wikitable"
|+
|+Table 1. IWGDF Risk of Foot Ulcer Formation
!'''Risk Category'''
!'''Risk Category'''
!'''Risk of Ulcer Formation'''
!'''Risk of Ulcer Formation'''
!'''Characteristics'''
!'''Characteristics'''
!'''Reassessment Frequence'''
!'''Reassessment Frequency'''
|-
|-
|0
|0
Line 33: Line 36:
* No LOPS
* No LOPS
* No PAD
* No PAD
|once a year
|Once a year
|-
|-
|1
|1
|Low
|Low
|LOPS or PAD
|LOPS or PAD
|once every 6-12 months
|Once every 6-12 months
|-
|-
|2
|2
|Moderate
|Moderate
|
|
* LOPS and PAD  
* LOPS and PAD
* OR LOPS and foot deformity  
* OR LOPS and foot deformity
* Or PAD and foot deformity
* Or PAD and foot deformity
|once every 3-6 months
|Once every 3-6 months
|-
|-
|3
|3
Line 55: Line 58:
* any lower-extremity amputation
* any lower-extremity amputation
* end-stage renal disease (ESRD)
* end-stage renal disease (ESRD)
|once every 1-3 months
|Once every 1-3 months
|}
|}
''Table is based on information provided by the IWGDF 2023 update.<ref name=":0" />''
''The above table is adapted from information provided in the IWGDF 2023 update.<ref name=":0" />''


== Neuropathy Assessment Checklist ==
== Neuropathy Assessment Guidelines ==
The use of an assessment checklist is recommended for consistent objective assessments, especially when following a patient over multiple visits and across time.  
The use of assessment guidelines or checklists is recommended to gather consistent objective assessments, especially when following a patient over multiple visits and across time.  


Benefits of an assessment checklist include:  
Benefits of an assessment checklist include:<ref name=":1" />


# ability to establish trends and identify changes over time to guide inventions
# ability to establish trends and identify changes over time to guide inventions
# facilitates communication among caregivers by providing objective and straight-forward information with consistent terminology
# facilitates communication among caregivers by providing objective and straight-forward information with consistent terminology
# clearly identify risks for developing foot ulcers so that they can be addressed and monitored
# clearly identify risks for developing foot ulcers so that they can be addressed and monitored
# opportunity to provide risk reduction education unique to the needs of the patient
# creates an opportunity to provide risk reduction education unique to the needs of the patient


=== Identifying an At-Risk Foot ===
Any person with diabetes is considered to have an "at-risk foot" or "diabetic foot disease" if they present with the risk of developing foot ulceration and or infection.<ref>Craus S, Mula A, Coppini DV. [https://www.rcpjournals.org/content/clinmedicine/23/3/228 The foot in diabetes–a reminder of an ever-present risk]. Clinical Medicine. 2023 May 17.</ref> Signs that a person with diabetes is at risk of foot ulceration include (1) LOPS, and (2) diagnosis of PAD.<ref name=":0" /> By assessing for changes in LOPS, a rehabilitation or wound care professional can screen for changes in a patient's risk for the development of diabetic foot ulcers. Prevention of a foot ulcer is more efficient clinically and financially than foot ulcer treatment and closure. '''''Please see the section below on Foot Ulcer Prevention for more information.'''''


So the checklist that I am going to use for this discussion was primarily one that was developed by the International Working Group on the Diabetic Foot, which is an international group of very expert clinicians, physicians primarily, who have had lots of experience in working with the diabetic foot and doing research involving neuropathy and the diabetic foot. And they came together and have a consensus over many of the things that need to be assessed and the interventions related to when you find a risk for these patients. And so this is the checklist because it is very comprehensive. I really recommend if the patient is newly diagnosed as a diabetic or it's your first visit with them in assessing them for all of the issues that are related to diabetes. One, you do a head-to-toe assessment, but directly related to neuropathy you do a very comprehensive foot and lower extremity assessment. There are other checklists out there that are much shorter. They're meant to be one to two minutes for an assessment, which are fine for interim type visits, or if you're really focusing on one particular area. But initially, you need that comprehensive assessment so that you can follow things over time.
Patients at very low risk for foot ulceration (IWGDF risk 0, please see Table 1) should be screened at least annually.<ref name=":0" /><ref name=":1" />
<blockquote>'''Annual Foot Screening''':<ref name=":0" />


=== Sensation ===
* Assess for presence of new or recurrent foot ulcer
So, the first thing that appears on most checklists is sensation. As I mentioned earlier, loss of protective sensation is one of the key indicators of a sensory neuropathy. And there are two ways to test for protective sensation. One is using a monofilament. The second is the vibratory sense. If you have a tuning fork that is 128 cycles per second, you can cause it to vibrate and put the post of it on the patient's foot in different areas. And if they sense the vibration, then their protective sensation is intact.  
* Assess for LOPS using one of the following methods:
** Pressure perception: Semmes-Weinstein 5.07<ref name=":1" /> or 10-gram monofilament<ref name=":1" /><ref name=":0" />
** Vibration perception: 128-Hz tuning fork<ref name=":1" />
** If monofilament or tuning fork are not available, test tactile sensation: lightly touch the tips of the patient's toes with the tip of the clinician's index finger for 1–2 seconds<ref name=":0" />
* Current vascular status: history of intermittent claudication, palpation of pedal pulses
</blockquote>
[[File:Monofilament testing sites.jpeg|center|thumb|500x500px|Primary and secondary testing monofilament testing sites]]


But by far the most common way is using the monofilament. So you need a 5,07 or a 10 gram monofilament, Semmes-Weinstein monofilament, to assess for loss of protective sensation, and I'm going to show this here at the camera if I can show it. You see that little silvery thread that's extending from the cardboard? That is the monofilament. So there is a very specific series of instructions in the process for using the monofilament to assess an individual's intact or loss of protective sensation. So the first thing you want to do is you want to show the patient on their hand or forearm, what the process is. So they can see what it looks like and they can feel it. Hopefully on the part of the body that you're using to demonstrate what it's going to feel like. Then you instruct the patient that whenever they feel that on their foot, they're to say yes, or give some kind of response that indicates that they are feeling that when you're touching their foot. You want to be careful that you don't coach them or clue them into the fact that you're going to touch them, so you don't want to repeat those instructions too often, but you may need to repeat them every now and then because the patient might get distracted or forget what you said, or you want to make sure they're paying attention.


So then you take the monofilament and you touch it against the patient's foot, and you allow it to bend. Sorry, let me see it right here. So you allow it to bend, and then you release it. It's about a two-second touch and release. You want to assess seven to ten sites on the plantar and dorsal surface of the foot. The primary sites are the plantar aspects of the first, third, and fifth toes, the met heads, the heel, and a couple areas on the dorsum of the foot. But you can't test on a callus, or an old scar, or in a wound. So that sometimes limits the areas that you can test. But once you get the response of the patient, and you're pretty sure that you got a valid response, you may need to repeat it in certain areas if you're not sure if they were guessing or if they weren't paying attention to make sure you have a valid finding. But then you can determine that they have partial or complete loss of protective sensation based on your findings.  
The following optional video demonstrates a monofilament assessment of the foot.
{{#ev:youtube| aQHDIkNSyxk |500}}<ref>YouTube. Monofilament Assessment of the Foot - OSCE Guide | Geeky Medics. Available from: https://www.youtube.com/watch?v=aQHDIkNSyxk [last accessed 01/September/2023]</ref>


=== Vascular Status ===
The following optional video demonstrates a tuning fork assessment of the foot.
The next thing that you need to assess is the vascular status of the patient. There are multiple mechanisms for assessing vascular status that you can do quickly at bedside or in a clinic, that you can then put together to give a picture of what's going on with the patient's arterial flow specifically. So one easy way to test that is doing the capillary refill test where you squeeze the toe, you release it and you time how long it takes for that blanching to return to the normal pink colour. Normal is 3 seconds or less, so anything greater than 3 seconds is a red flag, but they may have some kind of an arterial compromise. There are calluses on toes and stuff, which prevent you from doing capillary refill, as you might normally do, just on the big toe. So if you can't see blanching for whatever reason, on the toes, you might want to move further up the foot. And try just pressing an area on the foot, as long as you can get that blanching in time, how long it takes to return to normal colour, you get a sense of the integrity of their arterial flow.  
{{#ev:youtube| X3kW26L_7dA |500}}<ref>YouTube. Neurologic Examination of the Foot: The 128 Hz Tuning Fork Test | 360 Wound Care. Available from: https://www.youtube.com/watch?v=X3kW26L_7dA [last accessed 01/September/2023]</ref>


The second method is to palpate the pulses. And to get a true picture of what's going on in the foot, you need to palpate all of the pulses of the lower extremity, the femoral, the popliteal, the dorsalis pedis, the posterior tibialis at least to make sure that you have a good picture of what's going on with that patient's arterial flow. So when you start with the pedal pulses, you know, there's about 20% of the population that doesn't have a dorsalis pedis, so that's always one factor to consider. If you can't palpate the dorsalis pedis go to the posterior tibialis, and if you are able to, work your way up the leg. Because of reconstitution of vessels or formation of collateral vessels, sometimes you can palpate a pulse in the foot, but that doesn't mean that's enough of a blood flow to help heal a wound or to heal tissue damage. And you might identify they don't have a popliteal pulse, and that's really where the issue is. So that's why it's important to check the entire extremity.
== Comprehensive Examination Guidelines/Checklist ==
If a patient has either LOPS and/or PAD, they are at risk of ulceration (IWGDF risk 1-3, please see Table 1), and a more comprehensive examination is indicated.<ref name=":0" />


In addition to palpation, especially with patients who are diabetic, it's very valuable to use a Doppler to listen to the pulses. Even if you could palpate them, like I said, it doesn't mean they have adequate blood flow to heal a wound. So by listening with a Doppler, you can actually listen to the quality of the pulse sound. You're not just listening for whether or not they have a pulse, but you're trying to identify the quality. So a normal pulse sound through a Doppler should be triphasic. You should hear all three phases of the pulse as it's going through the Doppler. If you are only hearing a single sound, like a staccato constant, just one sound per beat, that is monophasic. Monophasic indicates there is a significant compromise of the arterial vasculature somewhere in the lower extremity. The in-between sound, the biphasic sound, is a little more difficult to sometimes identify. You might hear those two phases and then you're not sure if you hear that third one or not. So that one's a little bit more of a grey area. The other sound that you can commonly hear when you're listening for a pulse is what is defined or described as a rolling hills sound. It's kind of a whooshing sound that increases and decreases in volume over time. And that has been identified as a biphasic pulse. So that one's a little bit of a grey area, but for sure, if you hear all three pulses, you can be pretty confident they have an intact arterial flow. If you hear monophasic pulse, you know that they have a significant compromise to their arterial system that needs follow-up.
=== Detailed Medical and Social History ===
The following table lists foot-specific medical history questions recommended by the IWGDF. As always, use clinical judgment and explore other topics as warranted.
{| class="wikitable"
|+Table 2.
!'''Area of Questioning'''
!'''Clinical Reasoning'''
|-
|Previous ulceration<ref name=":1" /><ref name=":0" />
|The recurrence rate for diabetic foot ulcers is high, and areas of previous ulceration need to be protected and monitored for potential re-ulceration. Patient and caregiver education is vital to maintain skin integrity - please see the education section below for more details.
|-
|Previous amputation (minor or major)<ref name=":1" /><ref name=":0" />
|Lower limb amputation causes biomechanics changes in the remaining limb and alters the patient's gait pattern. Ulceration risk will shift to other areas of the remaining limb due to changes in pressure during weight-bearing and gait.
|-
|ESRD<ref name=":1" /><ref name=":0" />
|Patients with ESRD and diabetes mellitus have a significant increase in the frequency of diabetic foot ulcers, experiencing foot complications at more than twice the frequency and a rate of amputation 6.5-10 times higher than patients with diabetes alone.<ref>Papanas N, Liakopoulos V, Maltezos E, Stefanidis I. [https://scholar.google.com/scholar?output=instlink&q=info:0Jiny-WcYtEJ:scholar.google.com/&hl=en&as_sdt=0,44&scillfp=3010734153596097602&oi=lle The diabetic foot in end stage renal disease. Renal failure]. 2007 Jan 1;29(5):519-28.</ref>
|-
|Prior foot inspection education<ref name=":1" /><ref name=":0" />
|It is important to assess a patient's education and training carry-over from previous education sessions and identify any areas where additional education is needed.
|-
|Foot pain (at rest or with activity) or numbness<ref name=":0" />
|Changes in sensation (pain, burning, tingling, numbness, etc) in the feet is the most common symptom of diabetic neuropathy. A common presentation of this pain is to be worse at rest and improve with activity.
|-
|Mobility<ref name=":1" /><ref name=":0" />
|This should include functional mobility, gait assessment, balance assessment, durable medical equipment (DME) recommendations, and fall risk screening. Neuropathy can affect a patient's ability to efficiently and safely complete necessary mobility and increase their fall risk. Changes in gait dynamics can put the patient at risk of developing new foot wounds due to changing pressures over their feet.  
|-
|Social History
|
* Social isolation<ref name=":0" /> and availability of caregiver assistance
* Poor access to healthcare<ref name=":0" />
* Financial constraints<ref name=":0" />
* Home situation
* Transportation availability
|-
| colspan="2" |'''Other suggested interview topics'''
|-
|Claudication<ref name=":1" />
|Claudication presents as cramping, fatigue, or pain in the calf, thigh, or buttock after a set amount of time performing a physical activity such as walking. The pain is improved with rest and lower limb elevation. Claudication is a symptom of arterial insufficiency and can be the first indication of significant arterial obstruction to the lower limb.<ref>Smith RB III. Claudication. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 13. Available from: https://www.ncbi.nlm.nih.gov/books/NBK235/</ref>
|-
|Medication<ref name=":1" />
|Screen for medications or polypharmacy, which could affect balance. ''Please see the Resources section for more information and optional recommended reading on this topic.''
|}
''The above table is adapted from information provided in the IWGDF 2023 update<ref name=":0" /> and Diane Merwarth PT.''<ref name=":1" />


Then you can check skin temperature on the foot, which can also help identify a vascular problem. You want to make sure you check both feet, if the patient has both feet, and they haven't had an amputation, and if you're using your hands, you really should touch both feet at the same time, so you can compare the difference from side to side. Some people have naturally cold feet, so if they're equally cold, it may just be they have cold feet. But if one is significantly colder than the other or significantly warmer than the other, then again, that's an area that needs follow-up. It could be an infection, it could be a Charcot exacerbation, or it could be related to a vascular compromise. So further workup is really indicated.
'''To learn more about performing a fall risk screening/falls assessment, please see this [[Falls|optional additional article]].'''
=== Vascular Status ===
Although ischaemia is not considered a major cause of neuropathic wounds in a diabetic foot, it has been found to be a complication in over 65% of all individuals who develop a diabetic foot ulcer. Wound care professionals should refer patients back to their referring doctor for a more invasive vascular workup if they suspect arterial compromise.<ref name=":1" /> 
{| class="wikitable"
|+Table 3.
!'''Assessment'''
!'''Procedure'''
!'''Clinical Reasoning'''
|-
|Pedal pulses<ref name=":1" /><ref name=":0" />
|Assess all pulses of the lower limb (femoral, popliteal, dorsalis pedis, posterior tibialis) for a true clinical picture of vascular status:


Another way to assess the temperature in the foot is using an infrared thermometer. They are much more available these days. Although there is a cost involved, it's not an extremely high cost. It will provide a much more objective temperature reading, which is helpful when you're trying to identify subtle changes in the temperature of the foot. It is something, if the patient has one at home, that they can monitor the temperature of their feet daily. And if they detect a change in the temperature of their foot over two consecutive days of 2,2 degrees Celsius or more, then they need to notify their healthcare provider. And again, that could mean an infection. It could also mean a change in their arterial status or the onset of a Charcot exacerbation, which I will talk about later.  
* palpation
* Doppler
|
* 20% of the population does not have a dorsals pedis pulse.
* Assess the entire limb to assess if the patient has adequate blood flow for wound healing and identify the location of the potential vascular compromise.
|-
|Capillary refill<ref name=":1" /><ref name=":0" />
|[[Capillary Refill Test|Capillary refill test]]
|Tests the integrity of the patient's arterial flow, which has an effect on wound healing potential.
|-
|Skin temperature<ref name=":1" />
|
* Clinician comparison by touch
* Infrared thermometer
|
* Compare both feet.
* Changes in temperature could indicate infection, Charcot exacerbation or vascular compromise.
* The referring medical provider should be notified if there is a measured change in temperature over two consecutive days of 2.2 degrees Celsius or more.
|-
|Ankle pressure and [[Ankle-Brachial Index]] (ABI) OR
Toe pressure and Toe-Brachial Index<ref name=":1" /><ref name=":0" />
|Measures the ratio between the systolic blood pressure of the lower limb and the upper limb to assess for narrowing or blockages in the arteries in the legs.
|The ABI is not considered reliable in patients with chronic diabetes due to arterial wall stiffening. Instead, it is recommended that the toe-brachial index is completed if available.
|}


The other method of assessing a patient's vascular status is using either the ankle brachial index or toe pressures or the toe brachial index. The ankle brachial index should be a one-to-one ratio with normal blood flow. However, because of the medial calcinosis of the arteries of the lower leg and foot, those arteries become stiff, and so the application of pressure through the blood pressure cuff can be influenced by the stiffness of the artery, and you may have false readings when you're determining the ABI (ankle brachial index) in a patient. So it's my personal opinion that if you know a patient has diabetes, especially when they've had it for very long and it hasn't been well controlled, an ABI is really not valuable in identifying vascular problems in the lower extremity. So then you have to move to the toes where the arteries or the capillaries in the toes don't have that medial lining to become calcified. It requires a special Doppler with special little tiny blood pressure cuffs that can wrap around the toes to find the toe pressure compared to the brachial pressure and the ratios are pretty similar to the ABI index or you can just take the pressure of the pulse sound in the toe, if it's less than 30 millimetres of mercury in pressure, then that indicates that they have a vascular compromise in their foot and they need follow up.
''The above table is adapted from information provided in the IWGDF 2023 update<ref name=":0" /> and Diane Merwarth PT.''<ref name=":1" />


Once you have identified the potential risk of an arterial problem in the lower extremity, then that patient needs to be referred for more invasive type studies like arteriograms, with or without contrast, an arterial CAT (computed tomography) scan, something like that, that can further identify the risk where the arterial ischaemic problem is occurring and then to determine whether or not revascularisation is possible to help restore blood flow to the lower leg and foot. You don't want to use just one finding and call the vascular surgeon and say, I think this patient needs follow-up, unless it's the toe pressure or something that shows a very objective finding. But when you have multiple findings or multiple areas that suggest that there might be an arterial compromise, then using those objective numbers and then calling the vascular surgeon and saying, hey, I think this patient needs further workup, can help facilitate that workup from happening and then hopefully have an intervention that can help with that blood flow. Although ischaemia is not considered to be a major cause of the neuropathic wound in a diabetic foot, it has been found to be a complication in over 65% of all individuals who develop a diabetic foot ulcer.  
=== Skin Assessment ===
It is important to assess and compare both feet.
{| class="wikitable"
|+Table 4.
!'''Assessment'''
!'''Clinical Reasoning'''
|-
|Colour<ref name=":1" /><ref name=":0" />
|Autonomic changes related to peripheral neuropathy can result in changes in skin colour.
|-
|Temperature<ref name=":0" />
|Please see Table 3 for details
|-
|Callus<ref name=":1" /><ref name=":0" />
|A callus is a sign of abnormal pressures during gait. It must be removed as the callus itself can also act as a source of pressure. Removing the callus also enables the healthcare professional to visualise viable skin for proper assessment. Wounds can form under a callus and cannot be assessed or treated until the callus is removed.
|-
|Oedema<ref name=":0" />
|Autonomic changes related to peripheral neuropathy can result in distal extremity and foot swelling and oedema.
|-
|Pre-ulcerative signs<ref name=":1" /><ref name=":0" />
|Pre-ulcerative signs are related to autonomic neuropathy. Signs can include:


=== Foot Range of Motion ===
* haemorrhage<ref name=":1" />
The next area for assessment is range of motion. As I mentioned earlier, the stiffening of the tendons happens directly due to the influence of the chemical and cellular changes of diabetes. This causes a significant decrease in range of motion, which results in increased plantar pressure, because there isn't the flexibility of the foot during the gait sequence, which increases the risk of ulceration. The two primary areas that are the most serious and tend to be affected more frequently is the Achilles tendon shortening, which definitely decreases ankle dorsiflexion, and the flexor hallucis shortening, which causes the great toe to become stiff. And during propulsion and push off, there is less flexibility, and it puts point pressure right at the tip of the great toe, putting that at risk of developing a significant ulcer.
* decreased ability to sweat<ref name=":2">Packer CF, Ali SA, Manna B. [https://www.ncbi.nlm.nih.gov/books/NBK499887/ Diabetic ulcer]. 2023.</ref>
* dry cracked skin<ref name=":1" /><ref name=":2" />
* fissures in skin<ref name=":1" /><ref name=":2" />
|-
| colspan="2" |'''Other suggested skin assessment areas'''
|-
|Web spaces<ref name=":1" />
|Wounds can "hide" in these areas.
|-
|Plantarflexor creases at the base of the toes<ref name=":1" />
|Wounds can also be difficult to visualise in these areas, especially if a patient has foot deformities. Can also be at risk of mechanical injury if the patient has impaired sensation secondary to neuropathy.
|}
''The above table is adapted from information provided in the IWGDF 2023 update<ref name=":0" /> and Diane Merwarth PT.''<ref name=":1" />
=== Bone/Joint Assessment ===
Assess the patient while they are lying down and in standing, and compare bilaterally.
{| class="wikitable"
|+Table 5.
!'''Assessment'''
!'''Clinical Reasoning'''
|-
|Deformities<ref name=":1" />
|Foot deformities put patients at a greater risk for developing wounds due to abnormal pressures during weight bearing and gait. They also make it difficult for patients to find properly fitting shoes. Deformities can include:<ref name=":1" />


You also can develop the overall stiffness of the foot, from the skin thickening and the tendons thickening, it decreases the overall elasticity or suppleness of the foot. And as I mentioned earlier, that really affects the foot's ability to function as a shock absorber during gait. And you lose that accommodation that happens when you're walking over irregular surfaces or changing from one surface to another. And once this thickening of the collagen in the skin and the tendons develops, you lose all of that accommodation. And that puts pressure in areas that aren't used to bearing pressure during gait, and significantly increases the risk of developing an ulcer. There are some therapeutic interventions which I'll talk about in more detail later, but the earlier that you can identify that the tendons are shortening or the skin is thickening, you can work on stretching and strengthening and passive and active range of motion to try to mitigate some of those changes, or at least delay the onset that can lead to that increased risk of developing a wound.  
* claw toes
* hammer toes
* cross-over toes
* drifting toes
* excessively high arch
* flat feet
* wide feet
|-
|Excessive bony prominences<ref name=":1" />
|Abnormally large bony prominences can act as sources of internal pressure. Examples include:


=== Foot Appearance ===
* bunion at the first metatarsal head
The next thing you want to assess when you're looking at the patient's foot is any changes to the skin in general on the entire surface of the foot. So if you see dry, cracked, or fissured skin like I talked about previously, related to the autonomic neuropathy, there's potential for a break in the skin, especially deep in those fissures. So, if you are able to, if you have the equipment and feel qualified, or have someone who is qualified to work on this dry skin, you can use a pumice or some kind of an abrasion-type instrument to gently abrade away that dry cracked skin to decrease the depth of that fissure so you can visualise the base of the fissure to make sure there's no wounds or if there is a wound that you can get access to it and treat it effectively and hopefully prevent an infection from developing. You also want to make sure after you've used the pumice, if you have or any kind of other mechanism to try to get rid of some of that dry skin, that you moisturise that skin with some kind of a cream, preferably, or a lotion that will help moisturise and hydrate the skin. But you always want to make sure that that lotion doesn't go between the toes because that can cause an extra wetness and maceration inside between the toes.
* rocker bottom foot
|-
|Decreased joint mobility
|Tendons can stiffen due to chemical and cellular changes related to diabetes. This results in a decrease in foot and ankle range of motion. Decreased foot mobility will alter a patient's gait pattern, increase plantar pressures, decrease shock absorption ability, and increase the risk of ulceration. Primary areas of concern:


You're also looking for any callus formation. The earlier you can identify the start of a callus, the more quickly you can get that offloaded with footwear and work on shaving that callus down so that it doesn't become that rock in the shoe as the patient continues to walk on it. If you notice subcutaneous haemorrhaging, that dark red or almost black discolouration under the callus or inside the callus, that indicates that there's been tissue disruption causing that bleeding deep to the surface of the callus and that there's a wound present underneath that callus. So we want to shave the calluses down if we identify them, and if you aren't able to do that yourself, it's very important that you get them referred to someone who can. Because the smoother you keep the surface of that foot, the less bulky that callus is, the less pressure there will be when they continue to walk. It's very necessary that they get some kind of an insert or offloading device to help offload that callus as well. But until you can get that, or if you're not able to get that, shaving that callus and keeping it smooth will decrease the pressure. It won't eliminate the callus, but it will decrease the pressure and minimise the risk of a wound or at least again delay the onset of the wound.
* Achilles tendon tightness
* flexor hallucis tightness
* foot stiffness
|}
''The above table is adapted from information provided in the IWGDF 2023 update<ref name=":0" /> and Diane Merwarth PT.''<ref name=":1" />


When you are shaving a callus to the point where you may unroof the centre of it because there's like a cavity or a wound underneath there, those are most likely going to be in the areas where you've seen that subcutaneous haemorrhaging. You definitely need to educate the patient and/or their family members before you do this debridement that that discolouration indicates that there is a wound under there. So when you unroof the wound, the patient or their family member doesn't think that you personally caused that wound because you've already told them that there is a wound present and you're trying to get to it so you can care for it. So that education is extremely important.  
=== Sensation Assessment ===
{| class="wikitable"
|+Table 6.
!'''Assessment'''
!'''Procedure'''
!'''Clinical Reasoning'''
|-
|Reassess LOPS<ref name=":1" />
|For more information on this, please see the Annual Foot Screening box under the ''Identifying an At-Risk Foot heading.''
|Reassess for LOPS if previously noted to be present
|-
|[[Proprioception]]<ref name=":1" />
|There is limited consensus in the literature on how to test proprioception. Options include:


The next thing you're looking for is evidence of any '''previous ulcers or amputations'''. I mean, amputations are going to be pretty obvious. Hopefully the patient will have told you if they'd had previous ulcers, but sometimes they don't. And so, you know, looking for those scars can identify risk areas, because remember, once a wound has happened and then healed, the skin in the healed wound is never as strong as the skin was prior to the wound. So they're always at risk of breakdown. And as I said earlier, the recurrence rate for a diabetic neuropathic ulcer is extremely high. So identifying those areas, so again, you can protect them in appropriate footwear, monitor them over time is extremely important. You're also looking for areas where because of amputations, they've had biomechanical changes in their foot and that's altered their gait pattern, and now they have a risk of ulceration in other areas that maybe weren't at risk before, just because the amputation changed their whole gait sequence from that point forward.
* active versus passive positioning
* motion detection
* direction discrimination
|Proprioceptive sense is vital for proper balance, gait dynamics and sequencing, and fall prevention.
|}
''The above table is adapted from information provided by Diane Merwarth PT.''<ref name=":1" />


You want to identify any and all '''foot deformities'''. You're looking for, as I said before, previous amputations, whether they be major or minor, which can cause those biomechanical changes. You're looking for toe deformities, the claw toes, hammer toes, cross-over toes, drifting toes. All of those malpositioned toes can cause an increased risk for developing wounds, not only just during the gait sequence, but because they make finding a pair of shoes to fit their foot extremely difficult and wearing a shoe that doesn't fit with those deformities can increase their risk of developing ulcers as well.
=== Mental Health and Cognitive Disorders ===
{| class="wikitable"
|+Table 7.
!'''Assessment'''
!'''Clinical Reasoning'''
|-
|[[Dementia]]<ref name=":1" />
|A patient might present with dementia-related gait abnormalities, balance impairments, and fall risk. A dementia diagnosis may also affect the patient's discharge recommendations and need for assistance in the home setting.
|-
|[[Depression]]<ref name=":1" />
|A diagnosis of depression can affect balance
|}
''The above table is adapted from information provided in the IWGDF 2023 update<ref name=":0" /> and Diane Merwarth PT.''<ref name=":1" />


And then you want to look at the whole foot. You want to examine their arches. Do they have a really high arch? Do they have a flat foot? Do they have an extra wide foot? Are there excessive bony prominences like that first metatarsal head that causes a bunion, or the fifth metatarsal head? All of those structural changes that happen as the foot structures collapse, the muscle imbalance gets prolonged and exaggerated, and it causes lots of changes. The rocker bottom foot, which we will talk about more in the Charcot foot section of the module, and the extra wide foot. All of those increase the patient's risk of developing wounds because it's causing pressure on areas that are not used to sustaining pressure during gait.  
=== Footwear Assessment ===
Footwear provides protection from potential injury from the patient's environment. Ill-fitting shoes can be a source of pain, increase a patient's fall risk, and be a major factor in diabetic foot ulcer formation. A footwear assessment is an important part of the clinical assessment because it serves a preventative role in wound formation and can improve overall foot health.<ref>Ellis S, Branthwaite H, Chockalingam N. [https://link.springer.com/article/10.1186/s13047-022-00519-6 Evaluation and optimisation of a footwear assessment tool for use within a clinical environment]. Journal of Foot and Ankle Research. 2022 Feb 10;15(1):12.</ref>
{| class="wikitable"
|+Table 7.
!'''Assessment'''
!'''Clinical Reasoning'''
|-
|Ill-fitting<ref name=":1" /><ref name=":0" />
|
* Too tight: common in patients with diabetic neuropathy, can cause pressure injuries which can lead to wound formation<ref name=":1" />
* Too loose: can cause pistoning of the foot and heel in the shoe, which can result in friction and abrasion injuries and lead to wound formation<ref name=":1" />
|-
|Inadequate<ref name=":1" /><ref name=":0" />
|Damaged or broken shoes can increase fall risk and cause similar issues to skin integrity as ill-fitting shoes. Improper fastening due to missing laces or non-functioning velcro can also lead to similar issues.<ref name=":1" />
|-
|Lacking<ref name=":1" /><ref name=":0" />
|Patient's feet are not protected from environmental hazards, which puts them at significant risk for injury and wound formation.<ref name=":1" />
|}
''The above table is adapted from information provided in the IWGDF 2023 update<ref name=":0" /> and Diane Merwarth PT.''<ref name=":1" />


You want to then make sure you examine and inspect all areas of the foot that aren't covered in all of the previous sections, a kind of complete overall foot assessment. And again, doing that bilaterally, if at all possible, is crucial. You want to look in the web spaces. Wounds can hide in the base of the web spaces, and no one will know they're there until they can become infected and create a problem that way. You're looking for excessively dry skin, or more important for wound development, primarily excessively macerated skin or the wound itself. If you open the web space and you find that the skin between the toes is extremely moist and starting to macerate, you can put something as simple as a dry gauze 2x2 or small gauze pad between the toes. That will wick the moisture away, prevent the skin-to-skin contact that accentuates that moisture retention in between the toes and help dry out the skin so that it doesn't continue to be macerated and eventually break down.  
=== Foot Care Assessment ===
Assessing a patient's ability to complete their foot self-care is vital to maintaining foot health and wound prevention. This part of the foot assessment evaluates the patient's ability to reach, inspect, and care for their feet and nails. The assessing rehabilitation professional should note any physical limitations a patient presents with, which could limit their ability to perform foot self-care.


You want to be careful when you're inserting the gauze because it can be somewhat abrasive that you spread the toes open and put it down there without rubbing the skin that could potentially create a wound. But getting that gauze in there will really help. If they already have a wound or they are excessively wet and you're afraid that even a small gauze pad won't be enough to help absorb all that moisture, you can use some kind of a moisture wicking dressing product. The only one I'm familiar with is a transfer product that's made by Molnlycke. That wicks the moisture away and you can put the surface interface kind of in a horseshoe shape so that the tacky side is against the toes on both sides. It's a little challenging to get it down between the toes because it's sticky, but it really helps wick that moisture away. There may be other products on the market now, anything that helps wick the moisture to and away from the skin can help dry those web spaces out.
'''Physical limitations to self foot care include''':<ref name=":1" /><ref name=":0" />
# vision
# obesity
# decreased flexibility
{| class="wikitable"
|+Table 8.
!'''Assessment'''
!'''Clinical Reasoning'''
|-
|Toenail condition<ref name=":1" />''<ref name=":0" />''
|Patients with diabetes can present with thick, rough nails due to disease-associated changes in the keratin and vascular changes:


The same is true for the plantarflexor creases at the base of the toes. And with claw toes and hammer toes, sometimes those flexor creases, especially with claw toes, can be really tight and very closed in. So looking under there, a patient may remove his sock and inadvertently pull on the toe as he's removing the sock, not even realising that he's pulled on the toe because he has no sensation, and due to the inelasticity of the skin, actually causes a break at the base of the toe in that flexor crease. So again, looking for those, either the maceration from that skin-to-skin contact, from those really tight claw toes, or some kind of an accident, like pulling on the toe, but you're wanting to look for maceration or wounds. And again, you can insert dry gauze if it's just starting to macerate or you're concerned that it's too wet under there, or a wicking product if you have a wound to help get the moisture out of there and manage the wound at the same time.  
* integrity or condition of the nails
 
* improperly cut toenails<ref name=":1" />
The other thing that you want to look at is the '''integrity of the nails''' or the condition of the toenails in general. I know we've all seen patients with diabetes who come in with those really thick, jagged, rough nails that develop because of the changes in the keratin due to diabetes, as well as the vascular changes that are attributed to diabetes and the lack of care because the patient isn't able to care for their toenails. So you want to look at the integrity, look for minor fungal infections around them. You want to look at whether the patient is performing adequate hygiene, and if not, try to figure out why, if they're just not able to get to their foot, or they just haven't done it, so that you can work on education around that as well.  
|-
|State of cleanliness of feet and socks<ref name=":1" />''<ref name=":0" />''
|A patient's physical limitations (such as reduced vision, obesity, limited range of motion) may hinder their ability to adequately complete self-care and hygiene.''<ref name=":0" />'' Unclean feet and socks, especially moist socks, can provide an environment for unwanted bacterial growth and cause skin maceration.
|-
|Superficial fungal infection<ref name=":1" />''<ref name=":0" />''
|Superficial fungal infection is a consequence of maintaining a moist environment, such as damp socks and shoes, over the foot. Fungal infections are common in patients with diabetic foot ulcers and can lead to non-healing wounds. The early detection and treatment of fungal infection can improve patient wound healing and avoid amputations.<ref>Kandregula S, Behura A, Behera CR, Pattnaik D, Mishra A, Panda B, Mohanty S, Kandregula Sr S, BEHERA C. [https://www.cureus.com/articles/85336-a-clinical-significance-of-fungal-infections-in-diabetic-foot-ulcers.pdf A clinical significance of fungal infections in diabetic foot ulcers]. Cureus. 2022 Jul 14;14(7).</ref>
|}


And then looking at the length and the shape of the nail is important. The risks are varied when it comes to the length of toenails. If they're just too long in general, then they have trouble fitting in a good shoe and that can put pressure on the toenail and cause problems. More often though, you'll start to see those really long toenails kind of curl under to the point where they're actually starting to put pressure against the plantar surface of the same toe. And eventually that can cause a wound with a prolonged pressure and the sharpness of the nail. Or, as we've seen very often, they can curve to the side and start putting pressure on an adjacent toe and again, cause it to break the skin or put pressure that will cause the skin to break down over time. So it's important to keep those toenails trimmed as best as possible.
''The above table is adapted from information provided in the IWGDF 2023 update<ref name=":0" /> and Diane Merwarth PT.''<ref name=":1" />


You want to make sure that you advise the patient that they should never trim their own toenails. A family member should not do that either unless they have been specifically trained and determined to be competent to do so. If you are uncomfortable or don't feel competent to trim toenails, then it's important to refer them to a physician who does have the capability to do that, because the risk of that toenail is so great that trimming toenails is extremely important. If you're able to even just remove enough of the toenail so it's not putting pressure on the toe until you can get them referred, that is still helpful. If you are unable to do anything and you know that there's a risk of that toenail causing a wound, then you can at least put some kind of padding, a dry gauze pad, a thin foam pad that breaks that contact from the nail to the skin to try to give them time before any wound develops until they can get those toenails taken care of by the correct person.
<blockquote>
==== Special Topic: Toenail Care ====
Toenail care can be challenging for patients with diabetes. The disease can cause nails to thicken and make trimming difficult without specialised tools. In addition, physical limitations such as decreased vision, limited mobility, and difficulty accessing their feet can prevent patients from managing their own nail care. As a result, the toenails of patients with diabetes can grow to a length and girth, which puts pressure on the surrounding tissues and increases the risk of wound formation.<ref>Beuscher TL. [https://nursing.ceconnection.com/ovidfiles/00152192-201905000-00014.pdf Guidelines for diabetic foot care: A template for the care of all feet]. Journal of Wound Ostomy & Continence Nursing. 2019 May 1;46(3):241-5.</ref>


=== Footwear Assessment ===
'''Risks of improper diabetic nail care''': bacterial or fungal infection of the nails or in the surrounding soft tissue.<ref>Hillson R. [https://wchh.onlinelibrary.wiley.com/doi/10.1002/pdi.2124 Nails in diabetes]. Practical Diabetes. 2017 Sep;34(7):230-1.</ref>
Next, you want to examine the footwear. Do they have footwear? How does it fit? Is it too tight? Which, like I said before, is very common. Is it too loose? Which presents its own problems of pistoning in the shoe and causing friction and abrasion injuries that can lead to wounds. Is it inadequate? Is maybe there a hole in the sole of the shoe or the sole of the shoe is loose and it's flapping and that can cause a tripping hazard. As well as putting abnormal pressures wherever the sole is missing or it maybe folds under while they're walking. Or they don't have laces or velcro that secures the shoe to their foot and so it starts wobbling and they again piston inside the shoe and can cause problems that way, or do they not have any shoes, which is also a very common problem.  


So if they don't have shoes, whatever your resources are to try to find them something until they can get into the best footwear that's important for them is better than nothing. So cast shoes or post-op shoes can help protect the base of the foot until they can get into something better at a minimum if you have access to those. Foot hygiene, as I said before, is also important. You can look and see if the foot has been washed, if their socks are clean or not, because that can create problems as well, especially if they wear damp socks a lot. As well as looking for any kind of superficial fungal infections on the skin. If hygiene is an issue, then it's important to find out why they aren't performing hygiene on their feet. Some patients can't reach their feet or they're afraid to do anything because of their nails or they might have a wound or a callus. And there's multiple reasons why, but it's important to find out why and then educate and help find someone who can perform that hygiene if the patient is unable to do so.
'''Who can perform nail care''': only skilled and properly trained medical and rehabilitation professionals should trim the toenails of a patient with diabetes.<ref name=":1" /> The patient should not trim their own toenails. Family members/caregivers also should not perform nail care ''unless'' they have been specifically trained and determined to be competent.


=== Sensation, Balance, and Mobility Assessment ===
'''Nail shape matters''': trim toenails straight across and gently smooth any sharp edges with a nail file.</blockquote>
You also want to assess their proprioception, balance, gait, all of those functional components that are affected by the neuropathies that develop over time. So, proprioception has multiple components and it involves multiple senses. It's a very complex neurophysiologic process, but one of the ways to delineate different aspects of proprioception is to talk about the subsenses of proprioception. Things like whether it's active versus passive positioning, whether it's motion detection or direction discrimination, things that help the person know where their foot is or what part of their foot is doing what during gait is important to assess.  


You also want to think about are you assessing because you're trying to get something very specific from the interventions you're going to provide, which typically with a diabetic patient is not important. With your diabetic patient, you're trying to assess proprioception so that you can address those areas that are going to put them at risk for falling or developing wounds, those kinds of things. You're not trying to train them to become an elite athlete again, where the more sophisticated screening methods and assessment methods for proprioception are important. You're just looking at if they have an issue with where their foot is, then they're going to have a problem with gait and injuries to their foot subsequent to that.  
== Patient Education/Caregiver Training ==
* '''Foot Care Knowledge.''' Patient and caregiver knowledge and ongoing education are vital in reducing the risk of developing a diabetic foot ulcer. Providing patients with educational handouts and flyers has been found to improve education retention and decrease appointment "no-show" rates.<ref>Williams O'Braint Z, Stepter CR, Lambert B. [https://nursing.ceconnection.com/files/PreventiveNailCareAmongDiabeticPatientsAQualityImprovementInitiative-1669925883970.pdf Preventive Nail Care Among Diabetic Patients: A Quality Improvement Initiative]. Journal of Wound, Ostomy and Continence Nursing. 2022 Nov 1;49(6):559-63.</ref>
<blockquote>'''Topics of patient and caregiver education and training should include''':<ref>Alsaigh SH, Alzaghran RH, Alahmari DA, Hameed LN, Alfurayh KM, Alaql KB, Alsaigh S, Alzaghran R, ALAHMARI DA, Hameed L, Alfurayh K. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9812341/#REF16 Knowledge, Awareness, and Practice Related to Diabetic Foot Ulcer Among Healthcare Workers and Diabetic Patients and Their Relatives in Saudi Arabia: A Cross-Sectional Study]. Cureus. 2022 Dec 5;14(12).</ref>


There are a lot of studies in the literature talking about ways to assess for proprioception. There's not really a lot of consensus on whether one way is better than another when looking at proprioception. The various methods can be just touching the person on the plantar surface of their foot in different areas and have them identify where on the foot you're touching. Again, with a diabetic patient, that's difficult because they don't have sensation so they may not feel it to be able to identify where. You can passively move their toe or their foot in different directions and have them describe, are you moving it up or down to the side, to the inside, to the outside, those kinds of things. Those basic tests will probably enable you to identify that they have some kind of proprioception issue without going into a lot of elaborate testing with expensive equipment.
# daily inspection of the feet and between the toes
# daily foot hygiene
# avoid barefoot walking both indoors and outdoors
# wearing well-fitting, appropriate footwear
# who can and should trim the patient's toenails
# proper diet
# blood sugar monitoring
# exercise
# smoking cessation
</blockquote>
* '''Foot Ulcer Prevention Education'''
<blockquote>'''According to the IWGDF Prevention Guideline, there are five key elements to foot ulcer formation prevention:'''<ref name=":0" />
# identify the person with an at-risk foot
# regularly inspect and examine the feet of a person at risk for foot ulceration
# provide structured education for patients, their family and healthcare professionals
# encourage routine wearing of appropriate footwear
# treat risk factors for ulceration
</blockquote>


You're looking for the kinematic changes in the foot during gait, you know, there are foot deformities that can affect their motion during gait that cause biomechanical changes, as well as the biomechanical changes that may have occurred due to surgical interventions. Even amputation of a toe will biomechanically alter the foot, particularly if the tendons aren't repositioned to help prevent the drifting of the toes into the empty space or the altered muscle pull on the remaining toes based on the site of the amputation. Those all can cause biomechanical changes of the foot and change the gait pattern in general and put the patient at risk for wounds because of abnormal pressures in different areas. In addition, the decreased range of motion and the stiffness also affect the gait patterns and how they're moving on their feet during gait sequences.
== Resources  ==
 
Balance testing is also important. A lot of that also plays into proprioception. So you can kind of do some of those tests at the same time, but you're looking for balance changes that could be due to their lack of sensation. They don't know where their feet are to have the good base of support for balance, as well as the proprioceptive changes and the muscle weakness. So it's a complex series of things that you're trying to assess. And then doing a gait analysis, again, not to try to improve a person back to running or doing some kind of athletics, but to make them safe so that they have a good gait pattern that minimises their risks of wounds because of where they're putting pressure and how they're performing the gait sequence, as well as safety for tripping and balance and things like that.


So a '''fall risk assessment''' is important, especially with patients who are elderly or have had diabetes for a long period of time because their balance can change related to their proprioception and sensation and muscle strength and all of those things. So doing the balance impairment test using something like a modified Romberg is helpful to get that baseline and follow that over time. You're looking at their gait, especially the speed. If it's less than 0,6 metres per second, then it's too slow and they can have balance issues based on just walking too slow. And you might want to do some therapeutic interventions to help get a better pace during their walking. If they have visual impairment, that's going to affect their balance, of course. And as we know, vision is affected with diabetes pretty significantly. Do they have orthostatic hypotension, which may not be specific to a diabetic patient, but they could have orthostatic hypotension in addition to all of their other diabetes-related problems. And you need to know that to either have it treated or make sure the patient understands what's going on and how to accommodate to that.
==== Clinical Resources ====
'''Medication Review Resources:'''


=== Medication Review ===
* [https://www.cdc.gov/steadi/pdf/steadi-factsheet-medslinkedtofalls-508.pdf Medications Linked to Falls] Guideline for patients 65yo+ (Centers for Disease Control and Prevention)
Medications can cause balance problems, so a review of the medications, there's a lot of information online about what medications are known to affect a person's balance. And so, you know, if they are on a polypharmacy list of medications, then you may want to look at some of that to make sure that that's not affecting their balance. You want to assess their home environment, looking for tripping hazards, the poor lighting, things that can cause them to lose their balance and fall that can be corrected for to decrease the risk of that. Of course, if they have dementia, they could have gait abnormalities and balance issues because they're just not aware of what they're doing. And so getting them into a facility, maybe if they have advanced dementia, so they're safe, or making sure there's always someone with them so that they're protected is important.
* [https://www.hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/provider-portal/QMP/Medications.pdf Medications with Fall Risk Precautions] (Texas Health and Human Services)
* Spampinato SF, Caruso GI, De Pasquale R, Sortino MA, Merlo S. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7243111/ The treatment of impaired wound healing in diabetes: looking among old drugs]. Pharmaceuticals. 2020 Apr 1;13(4):60.


=== Depression Screening ===
'''Clinical Assessments:'''
And then if they have symptoms of depression, that can also affect their balance, partly because they just don't care or they're not paying attention, and they can be at risk for falling and injuring themselves for that. So, you know, physical therapy, occupational therapy, doing home assessments, and trying to minimise all of the risks that can be related to falls and other issues is important. That home evaluation should also include looking for the safety features that are important for patients who don't have good balance or are ageing, including grab bars at the tub and the toilet, safety rails by stairs or any kind of abnormal surfaces that they can hold on to. Looking for hazards, just plain clutter, loose rugs on the floor, do they have to manage a step or go up and down stairs that they might forget about or miss and ways to identify them better by putting coloured tape or something to help them see those steps better might be important. And then overall cleanliness, not necessarily because you want to know how clean they are, but because those can present safety issues as well. And then watching them perform ADL (activities of daily living) and IADLs (instrumental activities of daily living) in their home environment to see, are they safe doing them? Do they have all of the safety features that would help them better enable them to perform the activities of daily living are important.


=== Durable Medical Equipment (DME) ===
* [https://www.sralab.org/rehabilitation-measures/sharpened-romberg Sharpened Rhomberg]
And then considering whether or not they need DME. (durable medical equipment) Do they need an assistive gait device? Do they need offloading footwear, which we'll talk about later, but if they have the offloading footwear, then they probably need an assistive gait device as well because it can affect their balance, affect their function when they're upright. So the assistive gait devices can help with balance. It can also help offloading a foot if it's at risk for developing an ulcer if they use the device appropriately.
* [https://www.swrwoundcareprogram.ca/uploads/contentdocuments/hcpr%20-%20monofilament%20testing%20procedure.pdf Sensation testing monofilament form]
* [https://www.cdc.gov/diabetes/library/socialmedia/infographics/feet-healthy.html Infographic tips for health feet] (printable, Centers for Disease Control and Prevention)


== Resources  ==
*bulleted list
*x
or


#numbered list
Please view this optional 5-minute video for a demonstration of a foot neuropathy assessment.
#x
{{#ev:youtube| _BQdeaEHfZc |500}}<ref>YouTube. Diabetic Foot Examination - OSCE Guide  | Geeky Medics. Available from: https://www.youtube.com/watch?v=_BQdeaEHfZc [last accessed 01/September/2023]</ref>


== References  ==
== References  ==


<references />
<references />
[[Category:Plus Content]]
[[Category:Course Pages]]
[[Category:Foot - Assessment and Examination]]
[[Category:Foot]]
[[Category:Integumentary System]]

Latest revision as of 12:13, 22 November 2023

Original Editor - Stacy Schiurring based on the course by Diane Merwarth

Top Contributors - Stacy Schiurring, Jess Bell and Kim Jackson

Neuropathy Assessment[edit | edit source]

Diabetes is the leading cause of peripheral neuropathy worldwide.[1] Peripheral neuropathy can have devastating outcomes, including (1) foot ulcers, (2) major amputation, (3) falls, (4) intracranial injuries, and (5) decreased quality of life. Approximately one in four people with diabetes will develop a diabetic foot ulcer.[2]

Neuropathy, foot deformity, and trauma are the most common "triad of causes that interact and ultimately result in ulceration".[1] Proper assessment and identification of patients at risk for ulcer formation is vital in wound prevention and complication management.[1] This article provides an overview of a systematic method of foot neuropathy assessment. It also details foot self-care and prevention education.

For a review of foot neuropathy types, please see this article. Please see this article for a list of common wound care terminology.

Frequency of Assessment[edit | edit source]

The American Diabetes Association (ADA) Standards of Medical Care in Diabetes recommends all patients with diabetes be assessed for diabetic peripheral neuropathy:

However, depending on a patient's risk for foot ulcer formation, they may need to be reassessed more frequently.[4] The International Working Group on the Diabetic Foot (IWGDF) developed an evidence-based risk stratification system which provides recommendations on how often more at-risk patients with diabetes should be reassessed. The assignment of risk is based on the presence of:[5]

  1. lack of protective sensation (LOPS)
  2. peripheral artery disease (PAD)
  3. foot deformity
  4. other high-risk diagnoses or procedures (see Table 1 for details)
Table 1. IWGDF Risk of Foot Ulcer Formation
Risk Category Risk of Ulcer Formation Characteristics Reassessment Frequency
0 Very low
  • No LOPS
  • No PAD
 Once a year
1 Low LOPS or PAD Once every 6-12 months
2 Moderate
  • LOPS and PAD
  • OR LOPS and foot deformity
  • Or PAD and foot deformity
 Once every 3-6 months
3 High LOPS or PAD and one or more of the following:
  • previous foot ulcer
  • any lower-extremity amputation
  • end-stage renal disease (ESRD)
 Once every 1-3 months

The above table is adapted from information provided in the IWGDF 2023 update.[5]

Neuropathy Assessment Guidelines[edit | edit source]

The use of assessment guidelines or checklists is recommended to gather consistent objective assessments, especially when following a patient over multiple visits and across time.

Benefits of an assessment checklist include:[4]

  1. ability to establish trends and identify changes over time to guide inventions
  2. facilitates communication among caregivers by providing objective and straight-forward information with consistent terminology
  3. clearly identify risks for developing foot ulcers so that they can be addressed and monitored
  4. creates an opportunity to provide risk reduction education unique to the needs of the patient

Identifying an At-Risk Foot[edit | edit source]

Any person with diabetes is considered to have an "at-risk foot" or "diabetic foot disease" if they present with the risk of developing foot ulceration and or infection.[6] Signs that a person with diabetes is at risk of foot ulceration include (1) LOPS, and (2) diagnosis of PAD.[5] By assessing for changes in LOPS, a rehabilitation or wound care professional can screen for changes in a patient's risk for the development of diabetic foot ulcers. Prevention of a foot ulcer is more efficient clinically and financially than foot ulcer treatment and closure. Please see the section below on Foot Ulcer Prevention for more information.

Patients at very low risk for foot ulceration (IWGDF risk 0, please see Table 1) should be screened at least annually.[5][4]

Annual Foot Screening:[5]

  • Assess for presence of new or recurrent foot ulcer
  • Assess for LOPS using one of the following methods:
    • Pressure perception: Semmes-Weinstein 5.07[4] or 10-gram monofilament[4][5]
    • Vibration perception: 128-Hz tuning fork[4]
    • If monofilament or tuning fork are not available, test tactile sensation: lightly touch the tips of the patient's toes with the tip of the clinician's index finger for 1–2 seconds[5]
  • Current vascular status: history of intermittent claudication, palpation of pedal pulses
Primary and secondary testing monofilament testing sites


The following optional video demonstrates a monofilament assessment of the foot.

[7]

The following optional video demonstrates a tuning fork assessment of the foot.

[8]

Comprehensive Examination Guidelines/Checklist[edit | edit source]

If a patient has either LOPS and/or PAD, they are at risk of ulceration (IWGDF risk 1-3, please see Table 1), and a more comprehensive examination is indicated.[5]

Detailed Medical and Social History[edit | edit source]

The following table lists foot-specific medical history questions recommended by the IWGDF. As always, use clinical judgment and explore other topics as warranted.

Table 2.
Area of Questioning Clinical Reasoning
Previous ulceration[4][5] The recurrence rate for diabetic foot ulcers is high, and areas of previous ulceration need to be protected and monitored for potential re-ulceration. Patient and caregiver education is vital to maintain skin integrity - please see the education section below for more details.
Previous amputation (minor or major)[4][5] Lower limb amputation causes biomechanics changes in the remaining limb and alters the patient's gait pattern. Ulceration risk will shift to other areas of the remaining limb due to changes in pressure during weight-bearing and gait.
ESRD[4][5] Patients with ESRD and diabetes mellitus have a significant increase in the frequency of diabetic foot ulcers, experiencing foot complications at more than twice the frequency and a rate of amputation 6.5-10 times higher than patients with diabetes alone.[9]
Prior foot inspection education[4][5] It is important to assess a patient's education and training carry-over from previous education sessions and identify any areas where additional education is needed.
Foot pain (at rest or with activity) or numbness[5] Changes in sensation (pain, burning, tingling, numbness, etc) in the feet is the most common symptom of diabetic neuropathy. A common presentation of this pain is to be worse at rest and improve with activity.
Mobility[4][5] This should include functional mobility, gait assessment, balance assessment, durable medical equipment (DME) recommendations, and fall risk screening. Neuropathy can affect a patient's ability to efficiently and safely complete necessary mobility and increase their fall risk. Changes in gait dynamics can put the patient at risk of developing new foot wounds due to changing pressures over their feet.
Social History
  • Social isolation[5] and availability of caregiver assistance
  • Poor access to healthcare[5]
  • Financial constraints[5]
  • Home situation
  • Transportation availability
Other suggested interview topics
Claudication[4] Claudication presents as cramping, fatigue, or pain in the calf, thigh, or buttock after a set amount of time performing a physical activity such as walking. The pain is improved with rest and lower limb elevation. Claudication is a symptom of arterial insufficiency and can be the first indication of significant arterial obstruction to the lower limb.[10]
Medication[4] Screen for medications or polypharmacy, which could affect balance. Please see the Resources section for more information and optional recommended reading on this topic.

The above table is adapted from information provided in the IWGDF 2023 update[5] and Diane Merwarth PT.[4]

To learn more about performing a fall risk screening/falls assessment, please see this optional additional article.

Vascular Status[edit | edit source]

Although ischaemia is not considered a major cause of neuropathic wounds in a diabetic foot, it has been found to be a complication in over 65% of all individuals who develop a diabetic foot ulcer. Wound care professionals should refer patients back to their referring doctor for a more invasive vascular workup if they suspect arterial compromise.[4]

Table 3.
Assessment Procedure Clinical Reasoning
Pedal pulses[4][5] Assess all pulses of the lower limb (femoral, popliteal, dorsalis pedis, posterior tibialis) for a true clinical picture of vascular status:
  • palpation
  • Doppler
  • 20% of the population does not have a dorsals pedis pulse.
  • Assess the entire limb to assess if the patient has adequate blood flow for wound healing and identify the location of the potential vascular compromise.
Capillary refill[4][5] Capillary refill test Tests the integrity of the patient's arterial flow, which has an effect on wound healing potential.
Skin temperature[4]
  • Clinician comparison by touch
  • Infrared thermometer
  • Compare both feet.
  • Changes in temperature could indicate infection, Charcot exacerbation or vascular compromise.
  • The referring medical provider should be notified if there is a measured change in temperature over two consecutive days of 2.2 degrees Celsius or more.
Ankle pressure and Ankle-Brachial Index (ABI) OR

Toe pressure and Toe-Brachial Index[4][5]

Measures the ratio between the systolic blood pressure of the lower limb and the upper limb to assess for narrowing or blockages in the arteries in the legs. The ABI is not considered reliable in patients with chronic diabetes due to arterial wall stiffening. Instead, it is recommended that the toe-brachial index is completed if available.

The above table is adapted from information provided in the IWGDF 2023 update[5] and Diane Merwarth PT.[4]

Skin Assessment[edit | edit source]

It is important to assess and compare both feet.

Table 4.
Assessment Clinical Reasoning
Colour[4][5] Autonomic changes related to peripheral neuropathy can result in changes in skin colour.
Temperature[5] Please see Table 3 for details
Callus[4][5] A callus is a sign of abnormal pressures during gait. It must be removed as the callus itself can also act as a source of pressure. Removing the callus also enables the healthcare professional to visualise viable skin for proper assessment. Wounds can form under a callus and cannot be assessed or treated until the callus is removed.
Oedema[5] Autonomic changes related to peripheral neuropathy can result in distal extremity and foot swelling and oedema.
Pre-ulcerative signs[4][5] Pre-ulcerative signs are related to autonomic neuropathy. Signs can include:
Other suggested skin assessment areas
Web spaces[4] Wounds can "hide" in these areas.
Plantarflexor creases at the base of the toes[4] Wounds can also be difficult to visualise in these areas, especially if a patient has foot deformities. Can also be at risk of mechanical injury if the patient has impaired sensation secondary to neuropathy.

The above table is adapted from information provided in the IWGDF 2023 update[5] and Diane Merwarth PT.[4]

Bone/Joint Assessment[edit | edit source]

Assess the patient while they are lying down and in standing, and compare bilaterally.

Table 5.
Assessment Clinical Reasoning
Deformities[4] Foot deformities put patients at a greater risk for developing wounds due to abnormal pressures during weight bearing and gait. They also make it difficult for patients to find properly fitting shoes. Deformities can include:[4]
  • claw toes
  • hammer toes
  • cross-over toes
  • drifting toes
  • excessively high arch
  • flat feet
  • wide feet
Excessive bony prominences[4] Abnormally large bony prominences can act as sources of internal pressure. Examples include:
  • bunion at the first metatarsal head
  • rocker bottom foot
Decreased joint mobility Tendons can stiffen due to chemical and cellular changes related to diabetes. This results in a decrease in foot and ankle range of motion. Decreased foot mobility will alter a patient's gait pattern, increase plantar pressures, decrease shock absorption ability, and increase the risk of ulceration. Primary areas of concern:
  • Achilles tendon tightness
  • flexor hallucis tightness
  • foot stiffness

The above table is adapted from information provided in the IWGDF 2023 update[5] and Diane Merwarth PT.[4]

Sensation Assessment[edit | edit source]

Table 6.
Assessment Procedure Clinical Reasoning
Reassess LOPS[4] For more information on this, please see the Annual Foot Screening box under the Identifying an At-Risk Foot heading. Reassess for LOPS if previously noted to be present
Proprioception[4] There is limited consensus in the literature on how to test proprioception. Options include:
  • active versus passive positioning
  • motion detection
  • direction discrimination
 Proprioceptive sense is vital for proper balance, gait dynamics and sequencing, and fall prevention.

The above table is adapted from information provided by Diane Merwarth PT.[4]

Mental Health and Cognitive Disorders[edit | edit source]

Table 7.
Assessment Clinical Reasoning
Dementia[4] A patient might present with dementia-related gait abnormalities, balance impairments, and fall risk. A dementia diagnosis may also affect the patient's discharge recommendations and need for assistance in the home setting.
Depression[4] A diagnosis of depression can affect balance

The above table is adapted from information provided in the IWGDF 2023 update[5] and Diane Merwarth PT.[4]

Footwear Assessment[edit | edit source]

Footwear provides protection from potential injury from the patient's environment. Ill-fitting shoes can be a source of pain, increase a patient's fall risk, and be a major factor in diabetic foot ulcer formation. A footwear assessment is an important part of the clinical assessment because it serves a preventative role in wound formation and can improve overall foot health.[12]

Table 7.
Assessment Clinical Reasoning
Ill-fitting[4][5]
  • Too tight: common in patients with diabetic neuropathy, can cause pressure injuries which can lead to wound formation[4]
  • Too loose: can cause pistoning of the foot and heel in the shoe, which can result in friction and abrasion injuries and lead to wound formation[4]
Inadequate[4][5] Damaged or broken shoes can increase fall risk and cause similar issues to skin integrity as ill-fitting shoes. Improper fastening due to missing laces or non-functioning velcro can also lead to similar issues.[4]
Lacking[4][5] Patient's feet are not protected from environmental hazards, which puts them at significant risk for injury and wound formation.[4]

The above table is adapted from information provided in the IWGDF 2023 update[5] and Diane Merwarth PT.[4]

Foot Care Assessment[edit | edit source]

Assessing a patient's ability to complete their foot self-care is vital to maintaining foot health and wound prevention. This part of the foot assessment evaluates the patient's ability to reach, inspect, and care for their feet and nails. The assessing rehabilitation professional should note any physical limitations a patient presents with, which could limit their ability to perform foot self-care.

Physical limitations to self foot care include:[4][5]

  1. vision
  2. obesity
  3. decreased flexibility
Table 8.
Assessment Clinical Reasoning
Toenail condition[4][5] Patients with diabetes can present with thick, rough nails due to disease-associated changes in the keratin and vascular changes:
  • integrity or condition of the nails
  • improperly cut toenails[4]
State of cleanliness of feet and socks[4][5] A patient's physical limitations (such as reduced vision, obesity, limited range of motion) may hinder their ability to adequately complete self-care and hygiene.[5] Unclean feet and socks, especially moist socks, can provide an environment for unwanted bacterial growth and cause skin maceration.
Superficial fungal infection[4][5] Superficial fungal infection is a consequence of maintaining a moist environment, such as damp socks and shoes, over the foot. Fungal infections are common in patients with diabetic foot ulcers and can lead to non-healing wounds. The early detection and treatment of fungal infection can improve patient wound healing and avoid amputations.[13]

The above table is adapted from information provided in the IWGDF 2023 update[5] and Diane Merwarth PT.[4]

Special Topic: Toenail Care[edit | edit source]

Toenail care can be challenging for patients with diabetes. The disease can cause nails to thicken and make trimming difficult without specialised tools. In addition, physical limitations such as decreased vision, limited mobility, and difficulty accessing their feet can prevent patients from managing their own nail care. As a result, the toenails of patients with diabetes can grow to a length and girth, which puts pressure on the surrounding tissues and increases the risk of wound formation.[14]

Risks of improper diabetic nail care: bacterial or fungal infection of the nails or in the surrounding soft tissue.[15]

Who can perform nail care: only skilled and properly trained medical and rehabilitation professionals should trim the toenails of a patient with diabetes.[4] The patient should not trim their own toenails. Family members/caregivers also should not perform nail care unless they have been specifically trained and determined to be competent.

Nail shape matters: trim toenails straight across and gently smooth any sharp edges with a nail file.

Patient Education/Caregiver Training[edit | edit source]

  • Foot Care Knowledge. Patient and caregiver knowledge and ongoing education are vital in reducing the risk of developing a diabetic foot ulcer. Providing patients with educational handouts and flyers has been found to improve education retention and decrease appointment "no-show" rates.[16]

Topics of patient and caregiver education and training should include:[17]

  1. daily inspection of the feet and between the toes
  2. daily foot hygiene
  3. avoid barefoot walking both indoors and outdoors
  4. wearing well-fitting, appropriate footwear
  5. who can and should trim the patient's toenails
  6. proper diet
  7. blood sugar monitoring
  8. exercise
  9. smoking cessation
  • Foot Ulcer Prevention Education

According to the IWGDF Prevention Guideline, there are five key elements to foot ulcer formation prevention:[5]

  1. identify the person with an at-risk foot
  2. regularly inspect and examine the feet of a person at risk for foot ulceration
  3. provide structured education for patients, their family and healthcare professionals
  4. encourage routine wearing of appropriate footwear
  5. treat risk factors for ulceration

Resources[edit | edit source]

Clinical Resources[edit | edit source]

Medication Review Resources:

Clinical Assessments:


Please view this optional 5-minute video for a demonstration of a foot neuropathy assessment.

[18]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Boulton AJ, Armstrong DG, Albert SF, Frykberg RG, Hellman R, Kirkman MS, Lavery LA, LeMaster JW, Mills Sr JL, Mueller MJ, Sheehan P. Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes care. 2008 Aug 1;31(8):1679-85.
  2. ↑ Hicks CW, Wang D, Windham BG, Matsushita K, Selvin E. Prevalence of peripheral neuropathy defined by monofilament insensitivity in middle-aged and older adults in two US cohorts. Scientific reports. 2021 Sep 27;11(1):19159.
  3. ↑ American Diabetes Association Professional Practice Committee; 12. Retinopathy, Neuropathy, and Foot Care: Standards of Medical Care in Diabetes—2022. Diabetes Care 1 January 2022; 45 (Supplement_1): S185–S194.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 4.23 4.24 4.25 4.26 4.27 4.28 4.29 4.30 4.31 4.32 4.33 4.34 4.35 4.36 4.37 4.38 4.39 4.40 4.41 4.42 4.43 4.44 4.45 4.46 4.47 4.48 4.49 4.50 4.51 4.52 4.53 4.54 Merwarth, D. Understanding the Foot Programme. Assessment of Foot Neuropathies. Physioplus. 2023.
  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 5.19 5.20 5.21 5.22 5.23 5.24 5.25 5.26 5.27 5.28 5.29 5.30 5.31 5.32 5.33 5.34 5.35 5.36 5.37 5.38 5.39 5.40 Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Fitridge R, Game F, Monteiro‐Soares M, Senneville E, IWGDF Editorial Board. Practical guidelines on the prevention and management of diabetes‐related foot disease (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2023 May 27:e3657.
  6. ↑ Craus S, Mula A, Coppini DV. The foot in diabetes–a reminder of an ever-present risk. Clinical Medicine. 2023 May 17.
  7. ↑ YouTube. Monofilament Assessment of the Foot - OSCE Guide | Geeky Medics. Available from: https://www.youtube.com/watch?v=aQHDIkNSyxk [last accessed 01/September/2023]
  8. ↑ YouTube. Neurologic Examination of the Foot: The 128 Hz Tuning Fork Test | 360 Wound Care. Available from: https://www.youtube.com/watch?v=X3kW26L_7dA [last accessed 01/September/2023]
  9. ↑ Papanas N, Liakopoulos V, Maltezos E, Stefanidis I. The diabetic foot in end stage renal disease. Renal failure. 2007 Jan 1;29(5):519-28.
  10. ↑ Smith RB III. Claudication. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 13. Available from: https://www.ncbi.nlm.nih.gov/books/NBK235/
  11. ↑ 11.0 11.1 11.2 Packer CF, Ali SA, Manna B. Diabetic ulcer. 2023.
  12. ↑ Ellis S, Branthwaite H, Chockalingam N. Evaluation and optimisation of a footwear assessment tool for use within a clinical environment. Journal of Foot and Ankle Research. 2022 Feb 10;15(1):12.
  13. ↑ Kandregula S, Behura A, Behera CR, Pattnaik D, Mishra A, Panda B, Mohanty S, Kandregula Sr S, BEHERA C. A clinical significance of fungal infections in diabetic foot ulcers. Cureus. 2022 Jul 14;14(7).
  14. ↑ Beuscher TL. Guidelines for diabetic foot care: A template for the care of all feet. Journal of Wound Ostomy & Continence Nursing. 2019 May 1;46(3):241-5.
  15. ↑ Hillson R. Nails in diabetes. Practical Diabetes. 2017 Sep;34(7):230-1.
  16. ↑ Williams O'Braint Z, Stepter CR, Lambert B. Preventive Nail Care Among Diabetic Patients: A Quality Improvement Initiative. Journal of Wound, Ostomy and Continence Nursing. 2022 Nov 1;49(6):559-63.
  17. ↑ Alsaigh SH, Alzaghran RH, Alahmari DA, Hameed LN, Alfurayh KM, Alaql KB, Alsaigh S, Alzaghran R, ALAHMARI DA, Hameed L, Alfurayh K. Knowledge, Awareness, and Practice Related to Diabetic Foot Ulcer Among Healthcare Workers and Diabetic Patients and Their Relatives in Saudi Arabia: A Cross-Sectional Study. Cureus. 2022 Dec 5;14(12).
  18. ↑ YouTube. Diabetic Foot Examination - OSCE Guide | Geeky Medics. Available from: https://www.youtube.com/watch?v=_BQdeaEHfZc [last accessed 01/September/2023]
Retrieved from "https://www.physio-pedia.com/index.php?title=Assessment_of_Foot_Neuropathies&oldid=345484"