Annual Comprehensive Diabetes Foot Exam

Objectives

Completing the comprehensive annual foot exam will enable you to:

• Collect the necessary data to assess feet for risk of complications.

• Determine the need for referral to foot care specialists.

• Determine the patient’s risk status.

• Schedule self-management education.

• Document foot exam findings.

• Develop an appropriate management plan.

• Determine the need for therapeutic foot wear.

• Schedule follow-up care and referrals .

Instructions

Use copies of the annual comprehensive foot exam form to document findings, or incorporate the assessment questions and foot exam into an already existing overall diabetes care plan. A physician or other trained health care provider should conduct the foot exam. Prepare the patient for examination by removing shoes and socks/hose.

I. Presence of Diabetes Complications Complete the questions as directed.

Question 1: Does the patient have any history of the macro- and micro-vascular complications of diabetes or a previous amputation?

Patients who have been diagnosed with peripheral neuropathy, nephropathy, retinopathy, peripheral vascular disease or cardiovascular disease are likely to have had diabetes for several years and to be at risk for diabetes foot problems. A positive history of a previous amputation places the patient permanently in the high risk category. Specify the type and date of amputation(s).

Question 2: Does the patient have a foot ulcer now or a history of foot ulcer?

A positive history of a foot ulcer places the patient permanently in the high risk category. This person always has an increased risk for developing another foot ulcer, progressive deformity of the foot, and ultimately, lower limb amputation.
 

II. Current History Complete the questions as directed.

Question 1: Is there pain in the calf muscles when walking—i.e., pain occurring in the calf or thigh when walking less than one block that is relieved by rest?

This question is to determine whether the patient experiences intermittent claudication when walking. This pain is an indication of peripheral vascular disease or impaired circulation.

Question 2: Has the patient noticed any changes in the feet since the last foot exam?

Patients may notice changes in skin and nail condition or sensory perception if they are performing self-tests with a monofilament.

Questions 3 and 4: Has the patient experienced any shoe problems? Has the patient noticed any blood or other discharge in socks or hose?

New shoes can cause unexpected pressure and irritate underlying skin. Blood or other discharge from a foot wound can be the first indication of a severe foot problem.

Question 5: What is the patient's smoking history?

Cigarette smoking is a major risk factor for microvascular and macrovascular disease and is likely to contribute to diabetes foot disease.

Question 6: What is the patient’s most recent hemoglobin A1c test result?

Elevated hemoglobin A1c values are independently associated with a twofold risk of amputation.
 

III. Foot Exam Complete the questions or fill in the items as directed.

Item 1. Condition of the skin, hair and toenails.

Questions: Is the skin thin, fragile, shiny and hairless? Are the nails thick, too long, ingrown, or infected with fungal disease?

• Examine each foot between the toes and from toe to heel. Record any problems by drawing or labeling the condition on the foot diagram. Skin that is thin, fragile, shiny, and hairless is an indication of decreased vascular supply. Loss of sweating function may cause cracking of the skin and fissures that can become infected.

• Remove any nail polish. Check toenails to see if they are ingrown, deformed, or fungal. Thick nails may indicate vascular or fungal disease. If severe nail or dry skin problems are present, refer the patient to a podiatrist or a nurse foot care specialist.

Measure, draw in, and label the patient’s skin condition.

• Measure and draw on the form any corns, calluses, pre-ulcerative lesions (a closed lesion, such as a blister or hematoma), or open ulcers.

• Use the appropriate symbol to indicate what type of lesion is present—i.e., callus, ulcer, redness, warmth, maceration, pre-ulcerative lesion, fissure, swelling or dryness. Maceration is present if the tissue is friable, moist, and soft.

• Label areas that are significantly dry, red, or warm (warmer than other parts of the foot or the opposite foot).

Item 2: Musculoskeletal Deformities

• Foot deformities may be the result of diabetic motor neuropathy. The function of intrinsic muscles is lost, causing the toe digits to buckle as other muscles become imbalanced. Muscle wasting occurs. The plantar fat pad becomes displaced and the metatarsal heads become more prominent. Limited joint mobility occurs and contributes to the potential for toe and foot injury. If Charcot foot is present, there are severe bone and joint changes and the foot is swollen and warm to the touch.

  
  Hammer Toes

  
  Claw Toes

  
  Bunions (Hallux Valgus)

  
  Plantar View of Charcot Joint

   

• Indicate any of the foot deformities listed—i.e., toe deformities, bunions, foot drop, prominent metatarsal heads, or Charcot foot. The more serious deformities are illustrated above. Prominent metatarsal heads are evidence of major deformity such as midfoot collapse.

Item 3: Pedal Pulses

Check the pedal pulses (posterior tibial and dorsalis pedis) in both feet and note whether pulses are present or absent.

Item 4: Sensory Exam

The sensory testing device supplied in this kit is a 5.07 (10-gram) Semmes-Weinstein nylon monofilament mounted on a holder that has been standardized to deliver a 10-gram force when properly applied. Research has shown that a person who can feel the 10-gram filament in the selected sites is at reduced risk for developing ulcers. Because sensory deficits appear first in the most distal portions of the foot and progress proximally in a “stocking” distribution, the toes are the first areas to lose protective sensation.

• The sensory exam should be done in a quiet and relaxed setting. The patient must not watch while the examiner applies the filament.

• Test the monofilament on the patient’s hand so he/she knows what to anticipate.

• The five sites to be tested are indicated on the examination form.

• Apply the monofilament perpendicular to the skin’s surface (see diagram A below).

• Apply sufficient force to cause the filament to bend or buckle, using a smooth, not a jabbing motion (see diagram B below).

• The total duration of the approach, skin contact, and departure of the filament at each site should be approximately 1 to 2 seconds.

• Apply the filament along the perimeter and NOT ON an ulcer site, callus, scar or necrotic tissue. Do not allow the filament to slide across the skin or make repetitive contact at the test site.

• Press the filament to the skin such that it buckles at one of two times as you say “time one” or “time two.” Have patients identify at which time they were touched. Randomize the sequence of applying the filament throughout the examination.

• To order additional disposable or reusable monofilaments, see the Resource List.

  
  Apply the monofilament perpendicular to the skin’s surface.

  
  Apply sufficient force to cause the filament to bend or buckle.

   

IV. Risk Categorization

Based on the foot exam, determine the patient’s risk category. A definition of “low risk” or “high risk” for recurrent ulceration and ultimately, amputation, is provided in the following chart, along with minimum suggested management guidelines. Individuals who are identified as high risk may require a more comprehensive evaluation.

See the Resource List for obtaining information about other foot exam forms and risk categorization schemes developed by the Bureau of Primary Health Care’s Lower Extremity Amputation Prevention (LEAP) Program, Health Care Financing Administration, and the Veterans Administration.

Once feet are categorized as high risk, it is unlikely that risk status will change unless vascular surgery is performed. At subsequent visits the provider should assess for the development of additional risk factors and focus on maintaining the integrity of the feet and on metabolic control. Patients should be educated about avoidance of injury, use of therapeutic footwear, and preventive self-care.
 

V. Footwear Assessment

Question 1. Does the patient wear appropriate shoes?

Question 2. Does the patient need inserts?

Question 3. Should corrective footwear be prescribed?

Check inside shoes for foreign objects, torn lining, and proper cushioning. Improper or poorly fitting shoes are major contributors to diabetes foot ulcerations. Counsel patients about appropriate footwear. All patients with diabetes need to pay special attention to the fit and style of their shoes and should avoid pointed-toe and open-toe shoes, high heels, thongs and sandals. Assess the material and construction of footwear. Unbreathable and inelastic materials such as plastic should be avoided. Recommend use of materials such as canvas, leather, suede, and other materials that are breathable and/or elastic. Footwear should be adjustable with laces, Velcro, or buckles. Record the results of your footwear assessment.

Properly fitted athletic or walking shoes are recommended for daily wear. If off-the-shelf shoes are used, make sure that there is room to accommodate any deformities. High risk patients may require depth-inlay shoes or custom-molded inserts (orthoses), depending on the degree of foot deformity and history of ulceration. (See Medicare Coverage of Therapeutic Footwear.)

VI. Education

Question 1: Has the patient had prior foot care and other relevant diabetes education?

Question 2: Can the patient demonstrate appropriate foot care?

Indicate whether the patient has received prior education by checking yes or no in the blank. Patient education about foot care and other aspects of self-care is an essential component of preventive diabetes care. Observe whether the patient can demonstrate appropriate self-care of the feet. Refer for smoking cessation counseling if necessary. Determine whether the patient understands the need for, and results of, hemoglobin A1c tests.
 

VII. Management Plan

Complete the management plan, indicating actions for patient education, any diagnostic tests including hemoglobin A1c, footwear recommendations, referrals, and follow-up care.

Note: The management of foot problems may be the responsibility of different health care providers. For example, in some communities, certified nurses provide home health services or practice in primary care or foot care clinics to provide specialized diabetes foot care.

National Diabetes Education Program (NDEP)    http://ndep.nih.gov
NIDDK, National Institutes of Health, Bethesda, MD

A Joint Initiative of the National Institutes of Health and the
Centers for Disease Control and Prevention