What is the recommended method for charting pulses to the foot?

Standardized Method for Charting Pedal Pulses

The recommended method for charting pulses to the foot is to document pulse intensity numerically as: 0 (Absent), 1 (Diminished), 2 (Normal), or 3 (Bounding), specifying both the dorsalis pedis and posterior tibial pulses bilaterally. 1

Proper Examination Technique

Patient Positioning and Preparation

• Remove all lower extremity garments, including shoes and socks
• Position patient in a relaxed, comfortable state
• Ensure adequate lighting for visual inspection

Pulse Location and Assessment

1. Dorsalis Pedis Pulse:

   • Place index and middle fingers on the dorsum of the foot
   • Use the dorsal most prominence of the navicular bone as a landmark (typically the pulse is located about 10-11 mm from this landmark) 2
   • Apply gentle pressure to detect pulsations

2. Posterior Tibial Pulse:

   • Palpate in the groove between the medial malleolus and the Achilles tendon
   • Apply gentle pressure, as excessive pressure can obliterate the pulse

Documentation Format

Document findings for each foot using the standardized scale:

• 0 = Absent (not palpable)
• 1 = Diminished
• 2 = Normal
• 3 = Bounding

Example charting: "DP: Right 2/3, Left 1/3; PT: Right 2/3, Left 0/3"

When to Use Doppler Assessment

• If pulses are difficult to locate by palpation, use a handheld Doppler device to confirm presence 3
• Document Doppler findings as "present by Doppler" or "absent by Doppler"
• When using Doppler, record the quality of signals (monophasic, biphasic, or triphasic) 3

Clinical Significance of Pulse Findings

• Absence of both pedal pulses in a foot strongly suggests peripheral arterial disease (PAD) 4
• The presence of all four pedal pulses (bilateral dorsalis pedis and posterior tibial) is associated with a low likelihood of PAD 1
• The posterior tibial pulse absence is more diagnostically significant for PAD than dorsalis pedis absence, as the dorsalis pedis can be naturally absent in some healthy individuals 1

Additional Assessment When Pulses Are Abnormal

When documenting diminished or absent pulses, include:

• Ankle-Brachial Index (ABI) measurements if available 3
• Presence or absence of femoral bruits 4
• Any associated symptoms (rest pain, claudication)
• Skin temperature, color, and capillary refill time

Common Pitfalls to Avoid

• Attributing leg symptoms solely to arthritis or neuropathy without proper vascular assessment 1
• Failing to recognize that the dorsalis pedis pulse is easier to palpate but the posterior tibial pulse is more reliable for detecting PAD 5
• Relying solely on pulse palpation when ABI or other objective measurements are indicated, especially in patients with diabetes 3
• Not documenting both pulses in both feet, as bilateral assessment provides more complete diagnostic information 3

Remember that when pedal pulses are palpable, studies have shown ankle indices above 50% and toe systolic pressures above 40 mmHg, which generally indicate a relatively good prognosis for limb viability 6. However, complete vascular assessment should be performed in patients with suspected PAD or diabetes with foot ulceration.