What is the recommended physical examination and management approach for a patient with diabetic (DM) foot?

Physical Examination and Management of Diabetic Foot

All patients with diabetes should undergo a comprehensive foot examination at least annually to identify risk factors for ulceration and amputation, with more frequent examinations for those at higher risk. 1

Risk Factors for Diabetic Foot Complications

• Poor glycemic control 1
• Peripheral neuropathy with loss of protective sensation (LOPS) 1
• Peripheral arterial disease (PAD) 1
• Foot deformities (bunions, hammertoes, Charcot joint) 1
• Previous foot ulceration or amputation 1
• Preulcerative callus or corn 1
• Cigarette smoking 1
• Visual impairment 1
• Chronic kidney disease (especially patients on dialysis) 1

Comprehensive Foot Examination Components

1. History Assessment

• Previous ulcers or amputations 1
• Neuropathic symptoms (tingling, burning, pain especially at night) 1
• Vascular symptoms (claudication, rest pain) 1
• Foot care practices and footwear habits 1
• Smoking history 1

2. Neurological Assessment (for LOPS)

• 10-g Semmes-Weinstein monofilament test (primary test) 1
• Plus at least one additional test from: 1
  • Vibration perception using 128-Hz tuning fork 1
  • Pinprick sensation test 1
  • Ankle reflex assessment 1
  • Temperature sensation 1

Note: Absent monofilament sensation plus one abnormal test confirms LOPS, while at least two normal tests (with no abnormal test) rules out LOPS 1

3. Vascular Assessment

• Inspection for dependent rubor, pallor on elevation 1
• Palpation of dorsalis pedis and posterior tibial pulses 1
• Assessment of capillary refill time 1
• Ankle-brachial index (ABI) for patients with symptoms or signs of PAD 1
• Consider additional testing (toe pressure, transcutaneous oxygen pressure) in selected cases 1, 2

4. Dermatological Assessment

• Skin integrity 1
• Callus formation 1
• Pre-ulcerative lesions 1
• Color changes 1
• Temperature changes 1, 3
• Edema 1
• Interdigital spaces for maceration or fissures 3, 4

5. Musculoskeletal Assessment

• Foot deformities (claw toes, hammer toes, bunions) 1
• Bony prominences 1
• Limited joint mobility 1
• Charcot arthropathy 1

6. Footwear Assessment

• Proper fit (1-2 cm longer than foot, width equal to metatarsal phalangeal joints) 1, 2
• Adequate cushioning and support 1
• Signs of abnormal wear 1, 2
• Inspection of both inside and outside of shoes 1

Risk Stratification and Management

Based on the examination findings, patients should be classified according to risk and managed appropriately:

IWGDF Risk Classification System 1

• Category 0: No peripheral neuropathy - Annual examination
• Category 1: Peripheral neuropathy - Examination every 6 months
• Category 2: Peripheral neuropathy with PAD and/or foot deformity - Examination every 3-6 months
• Category 3: Peripheral neuropathy with history of foot ulcer or amputation - Examination every 1-3 months

Management Approach

1. Patient Education

• Daily foot inspection (using mirror for difficult-to-see areas) 1, 3
• Proper foot hygiene (washing, drying, moisturizing) 1, 3
• Appropriate nail and skin care 1
• Proper footwear selection 1
• Avoiding barefoot walking 1
• Recognition of early warning signs requiring medical attention 3, 5

2. Preventive Foot Care

• Regular callus debridement 1, 6
• Treatment of pre-ulcerative lesions (blisters, ingrown nails, fungal infections) 1, 5
• Management of dry skin with emollients (avoiding between toes) 1, 7

3. Footwear Recommendations

• Low-risk patients: Well-fitted off-the-shelf footwear 1, 2
• High-risk patients: Specialized therapeutic footwear 1
• Patients with deformities: Custom-molded shoes 1
• Patients with history of ulceration: Pressure-redistributing insoles 1, 2

4. Management of Detected Ulcers

• Classify ulcer type (neuropathic, ischemic, or neuro-ischemic) 1, 6
• Assess depth and presence of infection 1, 4
• Debride necrotic tissue and callus (except in ischemic ulcers) 1, 6
• Provide pressure offloading (total contact cast preferred for plantar ulcers) 1, 2
• Consider vascular assessment and revascularization for ischemic ulcers 1
• Treat infections with appropriate antibiotics 1, 6
• Consider advanced wound therapies for non-healing ulcers 1, 2

5. Multidisciplinary Approach

• Refer high-risk patients to foot care specialists 1
• Involve multidisciplinary team for complex cases 1
• Optimize glycemic control 1
• Address modifiable risk factors (smoking cessation, etc.) 1

Common Pitfalls to Avoid

• Failing to perform regular comprehensive foot examinations 4, 5
• Overlooking subtle signs of infection in neuropathic feet (may lack classic inflammatory signs) 1, 6
• Inadequate offloading of ulcers 2, 6
• Delaying vascular assessment in patients with PAD 1, 2
• Neglecting patient education on foot care 3, 5
• Inappropriate footwear selection 1, 2