This document discusses the examination of diabetic feet, which are at risk for ulcers and lower extremity amputation. There are three main causes of diabetic foot complications: neuropathy, foot deformity, and minor trauma. It is important for clinicians to check for loss of protective sensation, foot deformities, and history of foot problems. The foot examination should inspect for deformities, ulcers, skin and nail integrity, and evaluate sensation using tests like monofilament and vibration. Vascular assessment includes checking pulses, ankle-brachial index, and other blood flow measurements. A thorough diabetic foot exam can detect problems and help prevent further complications.

1. DIABETIC FOOT EXAMINATION

2. Diabetic Foot SyndromeNeuropathyPVDInfection

3. DFU and LEA will affect p to 25% of people with diabetes during their life times.Three component causes:Neuropathy

4. Foot deformity

5. Minor trauma (were detected in more than 63% of all ulcer.) DFU : Diabetic Foot UlcerLEA : Lower Extremity Amputation

6. 3 divisions of the PNSstocking/ glove distributionSensory LossWeaknessAbnormal ArchesHammared ToesMotor Impairmentdermal fissuresxerosisAutonomic Dysfunction

7. Important for clinician to ask the following questions:Does the patient have loss of protective sensation?Is foot deformity present?Does the patient have a history of ulceration, amputation or Charcot foot?

8. Foot Inspection For :Deformityulcershammer toes loss of archersCharcot foot Texture of skinIntegrity of skinTexture of nailsQuality of subcutaneous tissuePresence of hair

9. 1- DeformityOne must examine the foot for bony prominences and deformities. It is important to determine if a deformity is rigid or flexible as rigid deformities are often more difficult to accommodate conservatively and may need surgery.

11. 2- Ulcers :Wound depth: The depth of a wound is much more important for healing than the size of the wound. Wagener Gredes

12. Wound infection Wounds are considered infected if they have perulence and/or at least 2 of the following signs and symptoms: pain, warmth, erythema, oedema, lymphangitis or loss of function.

13. Ischemic Ulcer Wound ischemia can be diagnosed by the presence of necrotic tissue or gangrene within a wound, non palpable pulses or confirmatory vascular testing.

15. Charcot Foot

16. PalpationPedal Pulse :however, the presence of palpable pulses DOES NOT absolutely exclude peripheral arterial disease.

17. Femoral Pulse

18. Popleteal

19. Buergers Elevation Test• Elevate limb until dorsal veins emptied• Plantar surface of foot turns pale (1 min.)• (If severe - ? Widespread Insufficiency)

21. Special Tests

22. Monofilament Test:The monofilament should be placed against intact skin (without callus) and allowed to buckle.The patient should have his or her eyes closed during testing and be given a forced choice i.e. asked “ Do you feel the pressure at time A or time B?”

24. Testing 10 sites (plantar to toes and metatarsal heads 1, 3 and 5, plantar midfoot medial and lateral and planter heal , 1st web space

25. The person who cannot feel at least 7 of 10 pedal sites tested is considered to have an absent protective threshold.

26. Vibration Test :A 128 Hz tuning fork can be applied to the tip of the hallux and bony prominences.

27. It is important to give a non vibrating stimulus such as touch to verify that the person is giving a positive response to the vibration sense and not just to the touch sensation.

28. The vibratory perception threshold (VPT) meter or the biothesiometer can be used to quantify sensory loss and the progression of loss of nerve function by measurements at regular intervals.

29. Ankle Reflex

30. The Ankle Brachial Indexsystolic ankle pressure systolic arm pressureABI =The ABI is 95% sensitive and 99% specific for PAD.

31. In diabetic patient, the ABI is falsely elevated. Can assess the peripheral circulation by measuring the toe systolic pressure (normal > 40 mmHg) using either a strain gauge sensor or photoplethysmography.

33. Transcutaneous oxygen tension (normal > 40 mmHg) measurement has been used as non invasive measurement of limb perfusion.