What is the recommended approach for a diabetic foot exam in a patient with diabetes, particularly those with a history of foot problems or at high risk for developing them?

Diabetic Foot Examination Protocol

All patients with diabetes require a comprehensive foot examination at least annually, with the exam including inspection, neurological testing using a 10-g monofilament plus at least one additional test, and vascular assessment of pedal pulses. 1

Examination Frequency Based on Risk

• Low-risk patients (no neuropathy): Annual examination 1
• Moderate-risk patients (neuropathy alone, or neuropathy with PAD/deformity): Every 3-6 months 2, 3
• High-risk patients (prior ulcer/amputation, loss of protective sensation, structural abnormalities, or PAD): Every 1-3 months, with inspection at every clinical visit 1, 2

Required History Components

Obtain specific information about:

• Prior ulceration, amputation, Charcot foot, angioplasty, or vascular surgery 1
• Current neuropathic symptoms: pain, burning, numbness 1
• Vascular symptoms: leg fatigue, claudication, rest pain relieved with dependency 1
• Cigarette smoking status 1
• Presence of retinopathy and renal disease (especially dialysis) 1
• Visual impairment and foot care practices 1

Neurological Assessment for Loss of Protective Sensation (LOPS)

The 10-g Semmes-Weinstein monofilament test is the single most useful diagnostic tool and must be combined with at least one additional neurological test. 1, 3

Additional tests to perform (choose at least one):

• Pinprick sensation on dorsum of foot 1
• Temperature perception 1
• Vibration perception using 128-Hz tuning fork 1
• Ankle reflexes (Achilles tendon) 1

Interpretation: Absent monofilament sensation confirms LOPS; at least two normal tests with no abnormal tests rules out LOPS 1, 3

Vascular Assessment

Perform the following assessments:

• Palpation of dorsalis pedis and posterior tibial pulses bilaterally 1, 3
• Capillary refill time 1
• Rubor on dependency and pallor on elevation 1
• Venous filling time 1

Referral threshold: Patients with history of leg fatigue, claudication, rest pain relieved with dependency, or decreased/absent pedal pulses require ankle-brachial index testing and further vascular assessment 1, 3

Dermatological and Structural Assessment

Inspect for:

• Skin integrity: ulcers, calluses, erythema, warmth, breaks in skin, color changes 1, 3
• Foot deformities: bunions, hammertoes, claw toes, prominent metatarsal heads, Charcot foot 1
• Pre-ulcerative signs: callus formation, areas of increased pressure 1
• Limited joint mobility 1
• Poor foot hygiene 1

Examine patients both lying down and standing up, and inspect their shoes and socks (inside and outside). 1

Patient Education Requirements

Provide structured, repeated education covering:

• Daily foot inspection using palpation or visual inspection with an unbreakable mirror for patients with LOPS 1
• Proper foot hygiene: wash daily with water below 37°C, dry carefully between toes 1
• Appropriate footwear: wear seamless socks (or seams inside out), change socks daily, never walk barefoot 1, 2
• Nail and skin care techniques 1
• Avoidance of heating devices or hot-water bottles on feet 1
• When to seek immediate medical attention for foot problems 1

Multidisciplinary Referral Criteria

Refer immediately to foot care specialists for:

• Active foot ulcers 1
• History of prior ulceration or amputation 1
• Patients on dialysis 1
• Charcot foot 1
• Peripheral arterial disease with symptoms 1
• Smokers with prior lower-extremity complications, LOPS, structural abnormalities, or PAD 1

Common Pitfalls to Avoid

• Do not rely on symptoms alone: Patients may have asymptomatic neuropathy, PAD, or even ulcers 1
• Do not perform monofilament testing alone: Guidelines explicitly require at least one additional neurological test 1, 3
• Do not delay vascular referral: Patients with claudication or absent pulses need immediate ankle-brachial index and vascular surgery consultation 1
• Do not assume patients understand education: Evaluate whether patients have understood instructions, are motivated to act, and possess sufficient self-care skills 1