What is the recommended frequency and procedure for a diabetic foot exam?

Diabetic Foot Examination: Frequency and Procedure

All patients with diabetes must undergo a comprehensive foot examination at least annually, with high-risk patients requiring examinations every 1-3 months or at every clinical visit. 1, 2

Examination Frequency Based on Risk Stratification

The frequency of foot examinations depends critically on risk category:

• Low-risk patients (no neuropathy, no PAD, no deformities): Annual examination 1
• Moderate-risk patients (neuropathy OR PAD OR foot deformities): Every 3-6 months 1, 2
• High-risk patients (previous ulceration, amputation, neuropathy with PAD or deformities): Every 1-3 months or at every healthcare visit 1, 2
• Patients over 50 years: Should undergo noninvasive arterial studies screening, repeated every 5 years if normal 1

Comprehensive Foot Examination Components

History Assessment

Document the following specific elements:

• Previous complications: History of foot ulceration or lower-extremity amputation 1
• Vascular symptoms: Leg fatigue, claudication, rest pain relieved with dependency 1
• Neuropathic symptoms: Tingling or pain in lower limbs, especially at night 1
• Risk factors: Smoking history, exercise tolerance, end-stage renal disease, dialysis status, visual impairment 1, 2
• Social factors: Social isolation, poor access to healthcare, barefoot walking habits 1

Neurological Assessment for Loss of Protective Sensation (LOPS)

The 10-g Semmes-Weinstein monofilament test is the primary screening tool and must be combined with at least one additional neurological test to confirm LOPS. 1, 2

Perform these specific tests:

• 10-g monofilament: Test at multiple sites on each foot (plantar surfaces) 1
• Vibration perception: Use 128-Hz tuning fork on bony prominences 1, 2
• Pinprick discrimination: Test on dorsum of foot without penetrating skin 1
• Tactile sensation: Light touch with cotton wool on dorsum of foot or fingertip touch on toes for 1-2 seconds 1
• Ankle reflexes: Achilles tendon reflexes 1

LOPS is confirmed when monofilament sensation is absent AND one other neurological test is abnormal. 1 This finding places the patient at significantly higher risk, as peripheral neuropathy is a component cause in 78% of diabetic foot ulcerations. 1

Vascular Assessment

Examine for peripheral arterial disease through:

• Pulse palpation: Dorsalis pedis and posterior tibial arteries bilaterally 1
• Capillary refill time: Assess in toes 1
• Rubor on dependency and pallor on elevation: Position-dependent color changes 1
• Venous filling time: Observe after leg elevation 1

Critical threshold: Toe systolic blood pressures <30 mmHg indicate PAD and inability to heal foot ulcerations, requiring immediate vascular referral. 1

Important caveat: Ankle-brachial indices are often inaccurate in diabetic patients due to noncompressible vessels from medial arterial calcification; toe pressures are more reliable. 1

Dermatological Assessment

Inspect both feet with patient lying down AND standing up:

• Skin integrity: Look for cuts, blisters, redness, swelling, color changes, temperature differences 1, 3
• Pre-ulcerative lesions: Calluses, corns, areas of increased pressure 1
• Between toes: Check for maceration, fungal infection 1, 3
• Edema: Note any swelling 1

Musculoskeletal Assessment

• Foot deformities: Bunions, hammertoes, claw toes, prominent metatarsals, Charcot joint 1
• Bony prominences: Areas of increased plantar pressure 1
• Limited joint mobility: Assess ankle and toe range of motion 1

Footwear Assessment

Examine both the inside and outside of shoes and socks worn at home and outside:

• Fit and appropriateness: Check for adequate toe box, proper length and width 1
• Internal foreign objects: Feel inside shoes for debris or rough seams 1
• Wear patterns: Identify abnormal pressure points 1

Patient Education Requirements

Education must be provided in multiple sessions over time using various methods, as knowledge is quickly forgotten and requires regular reinforcement. 1

Daily Self-Examination Instructions

• Visual inspection: Check all surfaces of both feet daily, including between toes, using a mirror for difficult-to-see areas 3
• Palpation: Use hands to check for abnormalities when visual inspection is limited 3
• Warning signs: Look for cuts, blisters, redness, swelling, calluses, temperature changes 3

Immediate Medical Attention Triggers

Patients must seek care within 24 hours for:

• New ulcers or wounds 3
• Rapid changes in skin color 3
• Increased pain, redness, or swelling 3
• Any foot problem not beginning to heal within 24 hours 3

Referral Criteria

Refer to foot care specialists immediately for:

• Moderate to high-risk category patients 1
• Abnormal pulse volume recordings with toe pressures <30 mmHg and foot ulcers 1
• Any signs or symptoms of PAD requiring noninvasive arterial studies 1
• Active ulceration or infection 1

Common Pitfalls to Avoid

• Do not rely solely on patient symptoms: Patients with neuropathy may have asymptomatic ulcers or PAD 1
• Do not skip examination in patients without complaints: Absence of symptoms does not exclude foot disorders 1
• Do not use ankle-brachial index alone in diabetic patients: Noncompressible vessels make this unreliable; use toe pressures 1
• Do not perform annual screening only in high-risk patients: They require much more frequent monitoring 1, 2