What tests should be performed for a diabetic patient concerned about foot health due to a family history of diabetes mellitus (DM) complications, including amputation?

Diabetic Foot Screening Tests

For a diabetic patient concerned about foot complications, perform the 10-g Semmes-Weinstein monofilament test combined with at least one additional neurological assessment (vibration with 128-Hz tuning fork, pinprick, or ankle reflexes), inspect the skin for ulcers and deformities, and palpate pedal pulses. 1, 2

Essential Screening Components

Neurological Assessment for Loss of Protective Sensation (LOPS)

• The 10-g monofilament test is the single most important screening test and should be performed at multiple sites on each foot 3, 2
• Combine monofilament testing with at least one additional test: vibration perception using a 128-Hz tuning fork, pinprick sensation, temperature perception, or ankle reflexes 3, 1, 2
• Absent monofilament sensation confirms LOPS, while at least two normal tests with no abnormal findings rules out LOPS 3, 2
• The monofilament test is the most reproducible clinical examination for diabetic feet and detects 78% of patients who will develop foot ulcers 2, 4

Vascular Assessment

• Palpate dorsalis pedis and posterior tibial pulses in both feet 3, 1, 2
• Ask specifically about leg fatigue, claudication (pain with walking), and decreased walking speed 3, 2
• Assess capillary refill time, rubor on dependency, and pallor on elevation 2
• Perform ankle-brachial index (ABI) only if the patient has symptoms or signs of peripheral arterial disease on initial screening 1, 2

Dermatological and Musculoskeletal Examination

• Inspect all skin surfaces for ulcers, calluses, erythema, warmth, or breaks in skin integrity 3, 2
• Assess for foot deformities including bunions, hammertoes, prominent metatarsal heads, and Charcot foot 3, 2
• Check between all toes for maceration or fungal infection 1

Clinical History to Obtain

• Prior history of foot ulceration or amputation (like her brother) 3, 1
• Current neuropathic symptoms: pain, burning, numbness 3, 1
• Vascular symptoms: leg fatigue, claudication 3, 2
• Cigarette smoking status 3, 1
• Visual impairment status 3, 1
• Chronic kidney disease or dialysis 3, 1
• Current foot care practices 3, 2

Risk Stratification After Testing

Given her family history of amputation, she requires careful risk categorization:

• Category 0 (Very Low Risk): No peripheral neuropathy → annual screening 2
• Category 1 (Low Risk): Peripheral neuropathy alone → screening every 6-12 months 2
• Category 2 (Moderate Risk): Peripheral neuropathy with foot deformity or peripheral arterial disease → screening every 3-6 months 1, 2
• Category 3 (High Risk): History of foot ulcer or amputation → screening every 1-3 months 1, 2

Common Pitfalls to Avoid

• Do not rely on conventional clinical examination alone (pinprick, vibration, position sense) without monofilament testing, as these have poor reproducibility and low correlation with actual risk 4
• Do not perform ABI routinely on all diabetic patients; reserve it for those with symptoms or signs of peripheral arterial disease 1, 2
• Do not skip the monofilament test thinking other neurological tests are sufficient—it is the most validated screening tool for identifying at-risk feet 2, 4