Diabetic Foot Examination Procedure
The proper diabetic foot examination should include inspection, assessment of foot pulses, and testing for loss of protective sensation with the 10-g monofilament and at least one additional neurological test, with documentation of findings and risk stratification to guide follow-up frequency. 1
Components of a Comprehensive Diabetic Foot Exam
History
- Previous foot problems (ulcers, amputations)
- Symptoms of neuropathy (numbness, tingling, burning)
- Symptoms of vascular disease (claudication, rest pain)
- Diabetes duration and control
Visual Inspection
- Examine both feet completely, including between toes
- Check for:
- Skin integrity (cuts, blisters, ulcers)
- Callus formation
- Deformities (hammer toes, Charcot foot)
- Nail abnormalities
- Interdigital lesions (maceration, fissures)
- Color changes (redness, pallor)
- Edema
Neurological Assessment
10-g Semmes-Weinstein monofilament testing:
- Test at three specific sites on each foot
- Patient should correctly identify 2 out of 3 applications at each site
- Apply perpendicular to skin surface with enough force to bend the filament
At least one additional neurological test:
- Vibration sensation using a 128-Hz tuning fork
- Pinprick sensation test
- Ankle reflex assessment
Vascular Assessment
- Palpate dorsalis pedis pulse
- Palpate posterior tibial pulse
- Assess capillary refill time
- Note temperature and color of feet
Risk Stratification and Follow-up Planning
Based on examination findings, categorize patient risk and determine follow-up frequency:
| Risk Category | Characteristics | Examination Frequency |
|---|---|---|
| Very Low | No LOPS and no PAD | Annually |
| Low | LOPS or PAD | Every 6-12 months |
| Moderate | LOPS + PAD, or LOPS + foot deformity, or PAD + foot deformity | Every 3-6 months |
| High | LOPS or PAD and history of foot ulcer, amputation, or end-stage renal disease | Every 1-3 months |
Patient Education
- Daily foot inspection
- Proper washing and drying techniques
- Regular moisturizer application (not between toes)
- Appropriate footwear selection
- Avoiding barefoot walking
- Cutting toenails straight across
- Immediate reporting of any new lesions, discoloration, or pain
Special Considerations
When to Start Examinations
- Type 1 diabetes: At puberty or ≥10 years old (whichever comes first) AND after 5 years of diabetes duration
- Type 2 diabetes: At diagnosis 1
When to Refer to Specialists
Refer to foot care specialists if patient has:
- Loss of protective sensation
- Structural abnormalities
- History of prior ulcers or amputation
- Peripheral arterial disease
- Smoking with any risk factors 1
Common Pitfalls to Avoid
- Failing to remove shoes and socks for complete examination
- Incomplete inspection (forgetting interdigital spaces)
- Not documenting risk category
- Inadequate patient education
- Missing early signs of infection or ulceration
- Neglecting to provide appropriate follow-up based on risk category
Regular foot examinations with proper risk stratification and patient education can decrease ulcer occurrence by up to 50%, significantly reducing the risk of lower extremity amputation which is 17-40 times higher in diabetic patients compared to non-diabetics 2.