Diabetic Foot Assessment

For adults with diabetes, assess their risk of developing a diabetic foot problem:  
•  When diabetes is diagnosed and, thereafter, at least annually. 
•  If any foot problems arise or there is any discomfort. 
•  In any health clinic or on admission to hospital, if there is any change in their status. 
All healthcare professionals should at every interaction with a diabetic, examine the feet.

History

1. Duration of Diabetes
2. Medications (OHA and/or Insulin)
3. Hypertension
4. Cholesterol Level

5. Recent Blood Glucose Levels and its Trends 

6. Dietary Control

7. Weight Loss

8. Smoking and Alcohol

Specific History

1. Pain in Foot and Leg
2. Burning and Tingling 
3. Sensation 
4. Feeling of Numbness

5.Weakness 
6. Previous Ulcer or Amputations
7. History of Wounds that do not Heal 
8. Claudication Pain
9. Cramping Pain after Walking

 

Observation

Gait and Posture –

Type of Gait, Signs of Pain

Skin- Trophic Changes

  • Dryness 

  • Discoloration

  • Pigmentation

  • Hair Loss 

  • Excessive Sweating

  • Ingrown Nails

  • Dystrophy of Nails

  • Fungal Infection

  • Callus/Corns

  • Fissures and Wounds

  • Erythema

  • Swelling

Musculoskeletal Examination

Lower Limb Muscle Strength
Tightness
Tendo Achilles 

Biomechanics 
Joint Movement
Plantar Pressure Analysis

  • Static 

  • Dynamic (Gait Analysis) 

Neurological Examination

Semmes-Weinstein Monofilament 
(5.07) 10gm assesses protective sensation at 
10 sites on the foot

Vibration Perception
128Hz tuning fork, placed over the tip of the

big toe
Vibration Perception Threshold
Biothisiometer

Superficial Sensation
Light touch and pin prick 
Temperature

Differentiate hot and cold 
Reflex

Ankle Tendon reflex; Babinski Sign 

Deformities 

  • Hammer Toes

  • Clawing of Toes

  • Hallux-Valgus

  • Splaying of Feet

  • Prominent Metatarsal Head

  • Charcot Foot

  • High Arch

  • Flat Foot

Vascular Examination

Lower Limb Pulses
Dorsalis Pedes & Posterior Tibial Arteries
Skin Temperature
Difference from Proximal to Distal

Ankle Brachial Index (ABI)
The ratio between the systolic blood pressure of the leg and arm
Doppler Ultrasound

Footwear Examination

Check the Current Footwear
Age of Footwear
Wear and Tear
The area of erosion on the sole of the shoe
The area of overpressure on the insole

Type of Footwear
Open-toe
Closed-toe 
Offloading Custom shoe
MCP soft insole
Comfort 
Space between the big-toe and the toe-box ~ 1cm
Fit
Illfitting or tight
Orthoses or custom insoles, if any

Toe-grip sandals
Chappals
Sandals
Dress shoes Sports 

Plantar Pressure

Interaction between the plantar surface and the ground is important, because it is during weight bearing and walking that the process of ulceration begins. Both, within shoe and barefoot, plantar pressure system devices are available. Different devices are available that use different types of sensors (resistive, electrical, capacitor, etc.) to measure pressure. Plantar distribution during both static standing and walking can be visualized. Importance of a physician to perform foot examination and pedobarograpic assessment to prevent development of deformity and consequentially diabetic foot has also been established in a study1.
Plantar pressure measurement devices can help in predicting the risk, early detection, and diagnosis of diabetic foot ulcers and should be used in routine assessment of diabetic patients1,2.

Static Bipedal Standing:
In static standing: the subject stands barefoot on the pressure platform with arms at the either side of the trunk, gaze fixed looking forward, for about 20 seconds. The pressure map is displayed and gives us metrics about the maximum pressure, average pressure, arch index, area of the foot, and foot length. 

 

Dynamic Gait Analysis:
The subject walks barefoot on the platform in normal speed and gait. The 2-step gait is widely used in clinical practice. The pressure map is displayed and gives us metrics about the movement of the centre of pressure, foot progression angle, stance time, maximum pressure during each phase of stance, and pressure time integral. Pressure Transfer Tracker gives us the location and load at each region of the foot in a specific time during the stance phase.

 

Inference:

  • People with impaired glucose tolerance also have a significantly higher plantar pressure reading than normal, making assessment of plantar pressure important in assessment of foot in diabetics³.

  • Visualization of the pressure heat map and its metrics helps in educating the patient about the dynamics of his/her foot.

  • Visualize hallux-valgus angle, flat or high arched type foot, pressure distribution and center of pressure to aid in interventions.

  • In diabetics, the areas with callosities have higher pressure. The metatarsal head and the big toe has higher pressure in comparison to normal4.

  • The areas of high pressure once visualized can be treated with well-constructed offloading footwear or orthotics4.

  • Studies have also mentioned about the significance of pressure time integral in diabetics. In diabetes the pressure time integral and stance time is drastically increased in comparison to normal, this in addition to presence of deformity and neuropathy can lead to development of ulcers over higher pressure areas5. 

  • Moreover, plantar pressure distribution shows adverse changes, steadily with progression of disease and time since diagnosis, therefore timely reassessment of the plantar pressure is important4.

  • Using Pedobarobraphy guided insoles can relieve the pressure in high pressure areas by 30%, and reduced further over a year4.

1. Arun G Maiya, C.G. Sashi Kumar, et al. Plantar Pressure Distribution in Type 2 Diabetes Mellitus Without Peripheral Neuropathy. The Diabetic Foot Journal Middle East,2015; Volume 1, No. 2 
 

2. F. Fang, et al. Pedobarography- A Novel Screening Tool for Diabetic Peripheral Neuropathy? European Review for Medical and Pharmacological Sciences, 2013; 17: 3206-3212
 

3. Caroline Cabral Robinson, et al. Plantar Pressure Distribution Patterns of Individuals with Prediabetes in Comparison with Healthy Individuals and Individuals with Diabetes. Journal of Diabetes Science and Technology, 2013; (5): 1113-111

4. S.A. Bus, et al. Footwear and Offloading Interventions to Prevent and Heal Foot Ulcers And Reduce Plantar Pressure in Patients With Diabetes: A Systematic Review. Diabetes/ Metabolism Research and Reviews, 2015; 32(supp. 1): 99-118; doi: 10.1002/dmrr.2702
 

5. Malindu E. Fernando, et al. Plantar Pressures are higher in cases with diabetic foot ulcers compared to controls despite a longer stance phase duration. BMC Endocrine Disorder, 2016; 16:51; doi: 10.1186/s12902-016-0131-9

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