Diabetic Foot Screening Tests
For this patient with diabetes and a family history of amputation, perform a 10-g monofilament test combined with at least one additional neurological assessment (pinprick, temperature, vibration with 128-Hz tuning fork, or ankle reflexes), inspect the skin and assess for foot deformities, and palpate pedal pulses. 1
Core Screening Components
The American Diabetes Association explicitly recommends the following examination components for all diabetic patients at least annually 1:
Neurological Assessment (Primary Focus)
- 10-g Semmes-Weinstein monofilament test is the single most useful test to diagnose loss of protective sensation (LOPS), which is present in 78% of diabetic patients who develop foot ulcers 1, 2
- Combine monofilament with one additional test from: pinprick sensation, temperature perception, vibration with 128-Hz tuning fork, or ankle reflexes 1
- Absent monofilament sensation confirms LOPS, while at least two normal tests (with no abnormal tests) rules it out 1
- Clinical examination combined with the 10-g monofilament achieves 99% sensitivity when used together 3
Vascular Assessment
- Palpate dorsalis pedis and posterior tibial pulses in both feet 1
- Ask about leg fatigue, claudication, and rest pain relieved with dependency 1
- Assess capillary refill time, rubor on dependency, pallor on elevation, and venous filling time 1
- Perform ankle-brachial index (ABI) testing only if the patient has symptoms or signs of peripheral arterial disease (PAD) on initial screening 1
Dermatological and Musculoskeletal Assessment
- Inspect skin integrity for ulcers, calluses, erythema, warmth, or breaks in skin 1
- Assess for foot deformities including bunions, hammertoes, prominent metatarsal heads, and Charcot foot, which increase plantar pressures and ulceration risk 1
Clinical History to Obtain
Ask specifically about 1:
- Prior foot ulcers or amputations
- Neuropathic symptoms (pain, burning, numbness)
- Vascular symptoms (leg fatigue, claudication)
- Visual impairment
- Renal disease status
- Tobacco use
- Current foot care practices
Risk Stratification After Testing
Based on examination findings, classify the patient using the International Working Group on the Diabetic Foot system 1:
- Category 0 (Very Low Risk): No LOPS and no PAD → Annual screening
- Category 1 (Low Risk): LOPS or PAD → Screen every 6-12 months
- Category 2 (Moderate Risk): LOPS + PAD, or LOPS + foot deformity, or PAD + foot deformity → Screen every 3-6 months
- Category 3 (High Risk): LOPS or PAD plus history of ulcer, amputation, or end-stage renal disease → Screen every 1-3 months 1
Critical Pitfall to Avoid
Do not assume neuropathy based solely on family history or patient symptoms—objective confirmation with monofilament testing is essential for proper risk stratification and management planning 2. Given this patient's brother had amputation, she is already at heightened awareness but requires objective testing to determine her actual risk category and appropriate follow-up frequency.