What areas of the feet should be checked during a diabetic foot exam?

Key Areas to Check During a Diabetic Foot Examination

A comprehensive diabetic foot examination should include inspection of the skin, assessment of foot deformities, neurological assessment, and vascular assessment of specific areas to identify risk factors for ulceration and amputation. 1, 2

Areas for Visual Inspection

• Inspect all surfaces of both feet, including between the toes, looking for cuts, blisters, redness, swelling, calluses, or any other abnormalities 3
• Check areas at high risk for ulceration, including:
  • Plantar surface of the foot, especially under metatarsal heads 1
  • Heel region 1
  • Tips of toes, particularly the great toe 1
  • Areas between toes for maceration or infection 1, 3
  • Areas over bony prominences 1, 2
• Examine for foot deformities such as hammer toes, claw toes, hallux valgus, and prominent metatarsal heads that increase pressure points 1, 4
• Look for pre-ulcerative signs including calluses, corns, and areas of hyperemia 1, 5
• Check for skin temperature changes which may indicate inflammation 3, 2
• Inspect footwear for proper fit and areas of abnormal wear 1

Neurological Assessment Areas

• Test for loss of protective sensation (LOPS) using:
  • 10-g Semmes-Weinstein monofilament at specific sites: 1, 6
    • Plantar surface of hallux (great toe)
    • Plantar surface of 1st, 3rd, and 5th metatarsal heads
    • Dorsal surface of midfoot
    • Plantar heel
    • Between the first and second toes
  • Vibration perception using a 128-Hz tuning fork on the bony prominence of the great toe 1, 4
  • Pinprick sensation on the dorsal surface of the foot 1, 2
  • Ankle reflexes 1, 2

Vascular Assessment Areas

• Palpate pedal pulses: 1, 2
  • Dorsalis pedis artery (top of foot)
  • Posterior tibial artery (behind medial malleolus)
• Assess for signs of peripheral arterial disease: 1, 5
  • Skin color changes (pallor on elevation, rubor on dependency)
  • Temperature differences between feet and between different parts of the same foot
  • Capillary refill time at toenails
  • Hair loss on dorsum of foot and toes
  • Trophic changes in nails

Risk Stratification Based on Examination Findings

• Very low risk: No loss of protective sensation (LOPS) and no peripheral arterial disease (PAD) - examine annually 1, 5
• Low risk: LOPS or PAD without deformity - examine every 6 months 1, 5
• Moderate risk: LOPS or PAD with deformity - examine every 3-6 months 1, 5
• High risk: LOPS or PAD with history of ulcer or amputation - examine every 1-3 months 1, 5

Common Pitfalls to Avoid

• Failing to remove socks and shoes for a complete examination 1, 3
• Overlooking the spaces between toes where infections often begin 1, 3
• Neglecting to examine both feet, even if only one foot has symptoms 1, 2
• Relying solely on patient symptoms, as neuropathy may mask pain from serious conditions 1, 3
• Using only one sensory test instead of combining multiple tests (monofilament plus vibration or pinprick) 1, 6
• Forgetting to inspect the patient's footwear for proper fit and areas that may cause pressure 1, 5
• Assuming a normal appearance means no risk - neuropathy can be present without visible signs 1, 3

Remember that early detection of foot problems through comprehensive examination can prevent progression to serious complications including ulceration and amputation 3, 7.