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==Overview==
==Overview==
The main focus of [[diabetic foot]] [[screening]] should be on [[peripheral neuropathy]] detection, since [[foot]] [[ulcer]] development is rare in the absence of [[neuropathy]]. In addition to examining the [[peripheral neuropathy]], [[physicians]] should search for any evidence of [[skin]] integrity loss, [[anatomy|anatomical deformities]], [[Nail (anatomy)|nail]] changes and [[Anatomical terms of location|distal]] [[pulse|pulses]] when they [[screening|screen]] [[diabetes|diabetic]] [[patients]]. It is recommended to perform a careful [[foot]] [[physical examination|examination]] at least annually in [[diabetes|diabetic]] [[patients]] who are over the age of 15. Nevertheless, there are some risk stratification systems that can provide a better understanding of how often [[foot]] [[screening]] should be performed based on each [[patient]]. These systems utilize factors such as [[peripheral arterial disease]], impaired protective sensation of [[foot]], [[anatomy|anatomical deformities]], history of previous [[foot]] [[ulcer]] or [[amputation]] and presence of other concurrent disorders. One of the IWGDF guidelines on the management and [[Prevention (medical)|prevention]] of [[diabetic foot]] recommends a [[foot]] [[screening]] assessment sheet for [[physical examination]] in each [[screening]]. Physicians should educate [[patients]] to perform self [[foot]] [[physical examination|examinations]] more often. There are [[diagnpsis|diagnostic]] tools in order to perform a better [[screening]] such as Semmes-Weinstein monofilament, tuning fork and biothesiometer.


==Screening==
==Screening==
*The main focus of [[diabetic foot]] [[screening]] should be on [[peripheral neuropathy]] detection, since [[foot]] [[ulcer]] development is rare in the absence of [[neuropathy]]. However searching for other factors such as [[skin]] integrity, any [[wound]] or [[ulceration]], [[anatomy|anatomical deformities]], [[Nail (anatomy)|nail]] changes and [[Anatomical terms of location|distal]] [[pulse|pulses]] should not be missed during [[foot]] [[Physical examination|examination]].<ref name="pmid9472210">{{cite journal| author=Armstrong DG, Lavery LA, Vela SA, Quebedeaux TL, Fleischli JG| title=Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration. | journal=Arch Intern Med | year= 1998 | volume= 158 | issue= 3 | pages= 289-92 | pmid=9472210 | doi=10.1001/archinte.158.3.289 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9472210  }} </ref><ref name="pmid15680122">{{cite journal| author=Pinzur MS, Slovenkai MP, Trepman E, Shields NN, Diabetes Committee of American Orthopaedic Foot and Ankle Society| title=Guidelines for diabetic foot care: recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society. | journal=Foot Ankle Int | year= 2005 | volume= 26 | issue= 1 | pages= 113-9 | pmid=15680122 | doi=10.1177/107110070502600112 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15680122  }} </ref><ref name="pmid29146579">{{cite journal| author=Mishra SC, Chhatbar KC, Kashikar A, Mehndiratta A| title=Diabetic foot. | journal=BMJ | year= 2017 | volume= 359 | issue=  | pages= j5064 | pmid=29146579 | doi=10.1136/bmj.j5064 | pmc=5688746 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29146579  }} </ref>
*The main focus of [[diabetic foot]] [[screening]] should be on [[peripheral neuropathy]] detection, since [[foot]] [[ulcer]] development is rare in the absence of [[neuropathy]]. However, searching for other factors such as [[skin]] integrity, any [[wound]] or [[ulceration]], [[anatomy|anatomical deformities]], [[Nail (anatomy)|nail]] changes and [[Anatomical terms of location|distal]] [[pulse|pulses]] should not be omitted during [[foot]] [[Physical examination|examination]].<ref name="pmid9472210">{{cite journal| author=Armstrong DG, Lavery LA, Vela SA, Quebedeaux TL, Fleischli JG| title=Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration. | journal=Arch Intern Med | year= 1998 | volume= 158 | issue= 3 | pages= 289-92 | pmid=9472210 | doi=10.1001/archinte.158.3.289 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9472210  }} </ref><ref name="pmid15680122">{{cite journal| author=Pinzur MS, Slovenkai MP, Trepman E, Shields NN, Diabetes Committee of American Orthopaedic Foot and Ankle Society| title=Guidelines for diabetic foot care: recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society. | journal=Foot Ankle Int | year= 2005 | volume= 26 | issue= 1 | pages= 113-9 | pmid=15680122 | doi=10.1177/107110070502600112 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15680122  }} </ref><ref name="pmid29146579">{{cite journal| author=Mishra SC, Chhatbar KC, Kashikar A, Mehndiratta A| title=Diabetic foot. | journal=BMJ | year= 2017 | volume= 359 | issue=  | pages= j5064 | pmid=29146579 | doi=10.1136/bmj.j5064 | pmc=5688746 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29146579  }} </ref>
*A regular [[foot]] [[Physical examination|examination]] should be done in [[diabetes|diabetic]] [[patients]], in order to detecting [[peripheral neuropathy]], [[peripheral arterial disease]] and [[anatomy|anatomical]] [[foot]] deformities.<ref name="pmid23540807">{{cite journal| author=Brownrigg JR, Apelqvist J, Bakker K, Schaper NC, Hinchliffe RJ| title=Evidence-based management of PAD & the diabetic foot. | journal=Eur J Vasc Endovasc Surg | year= 2013 | volume= 45 | issue= 6 | pages= 673-81 | pmid=23540807 | doi=10.1016/j.ejvs.2013.02.014 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23540807  }} </ref>
*A regular [[foot]] [[Physical examination|examination]] should be done in [[diabetes|diabetic]] [[patients]], in order to detect [[peripheral neuropathy]], [[peripheral arterial disease]] and [[anatomy|anatomical]] [[foot]] deformities.<ref name="pmid23540807">{{cite journal| author=Brownrigg JR, Apelqvist J, Bakker K, Schaper NC, Hinchliffe RJ| title=Evidence-based management of PAD & the diabetic foot. | journal=Eur J Vasc Endovasc Surg | year= 2013 | volume= 45 | issue= 6 | pages= 673-81 | pmid=23540807 | doi=10.1016/j.ejvs.2013.02.014 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23540807  }} </ref>
*It is recommended to perform a careful [[foot]] [[physical examination|examination]] at least annually in [[diabetes|diabetic]] [[patients]] who are over the age of 15. Nevertheless physicians should educate [[patients]] to perform self [[foot]] [[physical examination|examination]] more often.  
*It is recommended to perform a careful [[foot]] [[physical examination|examination]] at least annually in [[diabetes|diabetic]] [[patients]] over the age of 15. Nevertheless, physicians should educate [[patients]] to perform self [[foot]] [[physical examination|examinations]] more often.  
*In [[diabetes|diabetic]] [[patients]] who have higher risk of [[diabetic foot]] [[ulcer|ulceration]] more frequent (every 1-6 months) [[physical examination|examinations]] and follow up should be considered.  
*In [[diabetes|diabetic]] [[patients]] who have higher risk of [[diabetic foot]] [[ulcer|ulceration]], more frequent (every 1-6 months) [[physical examination|examinations]] and follow-up should be considered.  
*An evidence‐based guideline published by the International Working Group on the [[diabetic foot]] (IWGDF) has demonstrated a risk stratification system for detecting [[diabetes|diabetic]] [[patients]] with high risk of [[foot]] [[ulcer|ulceration]]. The aforementioned guideline includes a scoring system which clarifies the proper intervals for [[screening]] [[diabetes|diabetic]] [[patients]].  The following table is a summary of this system:<ref name="pmid32176451">{{cite journal| author=Bus SA, Lavery LA, Monteiro-Soares M, Rasmussen A, Raspovic A, Sacco ICN | display-authors=etal| title=Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update). | journal=Diabetes Metab Res Rev | year= 2020 | volume= 36 Suppl 1 | issue=  | pages= e3269 | pmid=32176451 | doi=10.1002/dmrr.3269 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32176451  }} </ref><ref name="pmid32176447">{{cite journal| author=Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Hinchliffe RJ, Lipsky BA | display-authors=etal| title=Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update). | journal=Diabetes Metab Res Rev | year= 2020 | volume= 36 Suppl 1 | issue=  | pages= e3266 | pmid=32176447 | doi=10.1002/dmrr.3266 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32176447  }} </ref>
<br>
{| border="1"
! Characteristics !! Score !! Risk of ulcer development !! Recommended screening frequency
|-
! Intact protective sensation of [[foot]] <br> Absent of [[peripheral artery disease]]
! 0 || Very low || Annually
|-
! Impaired protective sensation of [[foot]]<br> OR <br> [[Peripheral artery disease]]
!1
!Low
!Every 6‐12 months
|-
! Impaired protective sensation of [[foot]] AND [[peripheral artery disease]] <br> OR <br> Impaired protective sensation of [[foot]] AND [[foot]] deformity <br> OR <br> [[Peripheral artery disease]] AND [[foot]] deformity
!2
!Moderate
!Every 3‐6 months
|-
! Impaired protective sensation of [[foot]] OR [[peripheral artery disease]] <br> AND at least one of the following: <br> Previous history of a [[foot]] [[ulcer]] <br> Previous history of [[amputation]] of a [[Human leg|lower extremity]] <br> [[Chronic renal failure|End‐stage renal disease]]
!3
!High
!Every 1‐3 months
|}
<br>
*One of the IWGDF guidelines on the management and [[Prevention (medical)|prevention]] of the [[diabetic foot]], published in 2011, recommended a [[foot]] [[screening]] assessment sheet for [[physical examination]] in each [[screening]]. The following table depicts this assessment sheet:<ref name="pmid22271742">{{cite journal| author=Bakker K, Apelqvist J, Schaper NC, International Working Group on Diabetic Foot Editorial Board| title=Practical guidelines on the management and prevention of the diabetic foot 2011. | journal=Diabetes Metab Res Rev | year= 2012 | volume= 28 Suppl 1 | issue=  | pages= 225-31 | pmid=22271742 | doi=10.1002/dmrr.2253 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22271742  }} </ref>
<br>
{| border="5" cellspacing="5" cellpadding="2"
| Search for [[anatomy|anatomical]] deformities or [[bone|bony]] prominences
|-
| Check the [[skin]] integrity
|-
| Monofilament test
|-
| Tuning fork test
|-
| Cotton wool sensation test
|-
| Search for any evidences of pressure on [[foot]], such as [[callus]] formation or discoloration
|-
| [[physical examination|Examine]] [[joints]] and search for abnormal [[joint]] mobility
|-
| Check [[pulses]], especially [[Posterior tibial artery|tibial posterior]] and [[Dorsalis pedis artery|dorsal pedal artery]]
|-
| Search for any evidence of previous [[ulcer]] and [[amputation]]
|-
| Evaluate [[foot]]wears
|}
 
 
*The following are some useful [[screening]] tools for [[diabetic foot]] [[screening]]:<ref name="pmid9448554">{{cite journal| author=Lavery LA, Armstrong DG, Vela SA, Quebedeaux TL, Fleischli JG| title=Practical criteria for screening patients at high risk for diabetic foot ulceration. | journal=Arch Intern Med | year= 1998 | volume= 158 | issue= 2 | pages= 157-62 | pmid=9448554 | doi=10.1001/archinte.158.2.157 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9448554  }} </ref><ref name="pmid1773715">{{cite journal| author=Kumar S, Fernando DJ, Veves A, Knowles EA, Young MJ, Boulton AJ| title=Semmes-Weinstein monofilaments: a simple, effective and inexpensive screening device for identifying diabetic patients at risk of foot ulceration. | journal=Diabetes Res Clin Pract | year= 1991 | volume= 13 | issue= 1-2 | pages= 63-7 | pmid=1773715 | doi=10.1016/0168-8227(91)90034-b | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1773715  }} </ref><ref name="pmid8545495">{{cite journal| author=Mueller MJ| title=Identifying patients with diabetes mellitus who are at risk for lower-extremity complications: use of Semmes-Weinstein monofilaments. | journal=Phys Ther | year= 1996 | volume= 76 | issue= 1 | pages= 68-71 | pmid=8545495 | doi=10.1093/ptj/76.1.68 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8545495  }} </ref><ref name="pmid16281925">{{cite journal| author=Forouzandeh F, Aziz Ahari A, Abolhasani F, Larijani B| title=Comparison of different screening tests for detecting diabetic foot neuropathy. | journal=Acta Neurol Scand | year= 2005 | volume= 112 | issue= 6 | pages= 409-13 | pmid=16281925 | doi=10.1111/j.1600-0404.2005.00494.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16281925  }} </ref>
*The following are some useful [[screening]] tools for [[diabetic foot]] [[screening]]:<ref name="pmid9448554">{{cite journal| author=Lavery LA, Armstrong DG, Vela SA, Quebedeaux TL, Fleischli JG| title=Practical criteria for screening patients at high risk for diabetic foot ulceration. | journal=Arch Intern Med | year= 1998 | volume= 158 | issue= 2 | pages= 157-62 | pmid=9448554 | doi=10.1001/archinte.158.2.157 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9448554  }} </ref><ref name="pmid1773715">{{cite journal| author=Kumar S, Fernando DJ, Veves A, Knowles EA, Young MJ, Boulton AJ| title=Semmes-Weinstein monofilaments: a simple, effective and inexpensive screening device for identifying diabetic patients at risk of foot ulceration. | journal=Diabetes Res Clin Pract | year= 1991 | volume= 13 | issue= 1-2 | pages= 63-7 | pmid=1773715 | doi=10.1016/0168-8227(91)90034-b | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1773715  }} </ref><ref name="pmid8545495">{{cite journal| author=Mueller MJ| title=Identifying patients with diabetes mellitus who are at risk for lower-extremity complications: use of Semmes-Weinstein monofilaments. | journal=Phys Ther | year= 1996 | volume= 76 | issue= 1 | pages= 68-71 | pmid=8545495 | doi=10.1093/ptj/76.1.68 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8545495  }} </ref><ref name="pmid16281925">{{cite journal| author=Forouzandeh F, Aziz Ahari A, Abolhasani F, Larijani B| title=Comparison of different screening tests for detecting diabetic foot neuropathy. | journal=Acta Neurol Scand | year= 2005 | volume= 112 | issue= 6 | pages= 409-13 | pmid=16281925 | doi=10.1111/j.1600-0404.2005.00494.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16281925  }} </ref>
**Semmes-Weinstein monofilament
**Semmes-Weinstein monofilament
Line 17: Line 67:
==References==
==References==
{{reflist|2}}
{{reflist|2}}
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Latest revision as of 14:09, 30 September 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]

Overview

The main focus of diabetic foot screening should be on peripheral neuropathy detection, since foot ulcer development is rare in the absence of neuropathy. In addition to examining the peripheral neuropathy, physicians should search for any evidence of skin integrity loss, anatomical deformities, nail changes and distal pulses when they screen diabetic patients. It is recommended to perform a careful foot examination at least annually in diabetic patients who are over the age of 15. Nevertheless, there are some risk stratification systems that can provide a better understanding of how often foot screening should be performed based on each patient. These systems utilize factors such as peripheral arterial disease, impaired protective sensation of foot, anatomical deformities, history of previous foot ulcer or amputation and presence of other concurrent disorders. One of the IWGDF guidelines on the management and prevention of diabetic foot recommends a foot screening assessment sheet for physical examination in each screening. Physicians should educate patients to perform self foot examinations more often. There are diagnostic tools in order to perform a better screening such as Semmes-Weinstein monofilament, tuning fork and biothesiometer.

Screening


Characteristics Score Risk of ulcer development Recommended screening frequency
Intact protective sensation of foot
Absent of peripheral artery disease 		0 Very low Annually
Impaired protective sensation of foot
OR
Peripheral artery disease 		1 Low Every 6‐12 months
Impaired protective sensation of foot AND peripheral artery disease
OR
Impaired protective sensation of foot AND foot deformity
OR
Peripheral artery disease AND foot deformity 		2 Moderate Every 3‐6 months
Impaired protective sensation of foot OR peripheral artery disease
AND at least one of the following:
Previous history of a foot ulcer
Previous history of amputation of a lower extremity
End‐stage renal disease 		3 High Every 1‐3 months



Search for anatomical deformities or bony prominences
Check the skin integrity
Monofilament test
Tuning fork test
Cotton wool sensation test
Search for any evidences of pressure on foot, such as callus formation or discoloration
Examine joints and search for abnormal joint mobility
Check pulses, especially tibial posterior and dorsal pedal artery
Search for any evidence of previous ulcer and amputation
Evaluate footwears


References

  1. ↑ Armstrong DG, Lavery LA, Vela SA, Quebedeaux TL, Fleischli JG (1998). "Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration". Arch Intern Med. 158 (3): 289–92. doi:10.1001/archinte.158.3.289. PMID 9472210.
  2. ↑ Pinzur MS, Slovenkai MP, Trepman E, Shields NN, Diabetes Committee of American Orthopaedic Foot and Ankle Society (2005). "Guidelines for diabetic foot care: recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society". Foot Ankle Int. 26 (1): 113–9. doi:10.1177/107110070502600112. PMID 15680122.
  3. ↑ Mishra SC, Chhatbar KC, Kashikar A, Mehndiratta A (2017). "Diabetic foot". BMJ. 359: j5064. doi:10.1136/bmj.j5064. PMC 5688746. PMID 29146579.
  4. ↑ Brownrigg JR, Apelqvist J, Bakker K, Schaper NC, Hinchliffe RJ (2013). "Evidence-based management of PAD & the diabetic foot". Eur J Vasc Endovasc Surg. 45 (6): 673–81. doi:10.1016/j.ejvs.2013.02.014. PMID 23540807.
  5. ↑ Bus SA, Lavery LA, Monteiro-Soares M, Rasmussen A, Raspovic A, Sacco ICN; et al. (2020). "Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update)". Diabetes Metab Res Rev. 36 Suppl 1: e3269. doi:10.1002/dmrr.3269. PMID 32176451 Check |pmid= value (help).
  6. ↑ Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Hinchliffe RJ, Lipsky BA; et al. (2020). "Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update)". Diabetes Metab Res Rev. 36 Suppl 1: e3266. doi:10.1002/dmrr.3266. PMID 32176447 Check |pmid= value (help).
  7. ↑ Bakker K, Apelqvist J, Schaper NC, International Working Group on Diabetic Foot Editorial Board (2012). "Practical guidelines on the management and prevention of the diabetic foot 2011". Diabetes Metab Res Rev. 28 Suppl 1: 225–31. doi:10.1002/dmrr.2253. PMID 22271742.
  8. ↑ Lavery LA, Armstrong DG, Vela SA, Quebedeaux TL, Fleischli JG (1998). "Practical criteria for screening patients at high risk for diabetic foot ulceration". Arch Intern Med. 158 (2): 157–62. doi:10.1001/archinte.158.2.157. PMID 9448554.
  9. ↑ Kumar S, Fernando DJ, Veves A, Knowles EA, Young MJ, Boulton AJ (1991). "Semmes-Weinstein monofilaments: a simple, effective and inexpensive screening device for identifying diabetic patients at risk of foot ulceration". Diabetes Res Clin Pract. 13 (1–2): 63–7. doi:10.1016/0168-8227(91)90034-b. PMID 1773715.
  10. ↑ Mueller MJ (1996). "Identifying patients with diabetes mellitus who are at risk for lower-extremity complications: use of Semmes-Weinstein monofilaments". Phys Ther. 76 (1): 68–71. doi:10.1093/ptj/76.1.68. PMID 8545495.
  11. ↑ Forouzandeh F, Aziz Ahari A, Abolhasani F, Larijani B (2005). "Comparison of different screening tests for detecting diabetic foot neuropathy". Acta Neurol Scand. 112 (6): 409–13. doi:10.1111/j.1600-0404.2005.00494.x. PMID 16281925.

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