What to include in a pedal pulses assessment?

Pedal Pulses Assessment: Essential Components and Technique

A comprehensive pedal pulses assessment should include inspection, palpation of both dorsalis pedis and posterior tibial pulses, assessment of pulse quality, and calculation of the ankle-brachial index (ABI) when indicated. 1

Core Components of Pedal Pulses Assessment

1. Visual Inspection

• Examine skin color, temperature, and integrity
• Look for signs of:
  • Pallor on elevation
  • Rubor on dependency
  • Trophic changes (hair loss, thin/shiny skin)
  • Ulcerations or wounds
  • Callus formation
  • Foot deformities 1

2. Pulse Palpation Technique

• Dorsalis Pedis Pulse:

  • Located on dorsum of foot between 1st and 2nd metatarsals
  • Use pads of index and middle fingers with gentle pressure

• Posterior Tibial Pulse:

  • Located behind and below the medial malleolus
  • Use pads of index and middle fingers with gentle pressure 1

3. Pulse Quality Documentation

• Document using a standardized scale:
  • 0 = Absent/non-palpable
  • 1 = Diminished/weak
  • 2 = Normal
  • 3 = Bounding/increased 1

4. Ankle-Brachial Index (ABI) Assessment

• Indicated when pulses are diminished or absent
• Calculate by dividing ankle systolic pressure by brachial systolic pressure
• Interpretation:

  • 1.30: Poorly compressible vessels/arterial calcification

  • 0.90-1.30: Normal
  • 0.60-0.89: Mild arterial obstruction
  • 0.40-0.59: Moderate obstruction
  • <0.40: Severe obstruction 1

Advanced Assessment When Indicated

1. Doppler Assessment

• Use handheld Doppler device when pulses are difficult to palpate
• Apply conductive gel and position probe at 45° angle
• Document waveform characteristics (triphasic, biphasic, monophasic) 1, 2

2. Additional Vascular Measurements

• Toe pressures (when ABI >1.30 suggests calcification)
• Toe-brachial index (TBI): normal >0.70
• Transcutaneous oxygen pressure (TcPO2): normal ≥25 mmHg 1, 3

Clinical Significance and Interpretation

1. Diagnostic Value

• Important caveat: Pulse palpation alone has limited sensitivity (17.8-32.4%) but high specificity (97.8-98.7%) for detecting PAD 4
• The presence of palpable pulses generally indicates:
  • Ankle index >50%
  • Toe pressure >40 mmHg
  • Low probability of severe arterial disease 5
• Absence of pulses in both feet strongly suggests PAD (ankle index <90%) 5, 6

2. Risk Stratification

• Use findings to classify foot risk using IWGDF risk stratification:
  • Category 0 (Very low): No LOPS and no PAD - Annual examination
  • Category 1 (Low): LOPS or PAD - Examination every 6-12 months
  • Category 2 (Moderate): LOPS + PAD or foot deformity - Examination every 3-6 months
  • Category 3 (High): History of ulcer/amputation or ESRD - Examination every 1-3 months 1

Documentation Best Practices

• Record date and time of assessment
• Document specific pulse locations assessed
• Note pulse quality for each location using standardized scale
• Include ABI values when measured
• Document any abnormal findings or asymmetry between feet
• Note any limitations in assessment (e.g., edema, pain)
• Include comparison to previous assessments when available 1

Common Pitfalls to Avoid

1. Relying solely on pulse palpation: Palpation has significant inter-observer variability and limited sensitivity; complement with ABI when indicated 7, 2

2. Applying excessive pressure: May obliterate pulses, leading to false-negative findings

3. Mistaking examiner's pulse for patient's: Ensure proper finger positioning

4. Overlooking arterial calcification: High ABI (>1.30) may indicate noncompressible vessels rather than absence of PAD 1, 3

5. Failing to compare bilaterally: Always assess and compare both feet to detect asymmetry

6. Neglecting to assess both dorsalis pedis and posterior tibial pulses: The posterior tibial pulse is generally more reliable for PAD assessment 7