Diabetic foot physical examination: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Diabetic foot}} | {{Diabetic foot}} | ||
{{CMG}} {{AE}} {{VVS}} | {{CMG}} {{AE}} {{Anahita}} {{VVS}} | ||
==Overview== | |||
[[Patients]] with [[diabetic foot]] [[ulcer]] could appear ill if [[ulcers]] are severe or [[infection|infected]]. In severe and [[Chronic (medical)|chronic]] [[infection|infected]] [[ulcers]] [[patients]] may have [[fever]], [[tachycardia]] and low [[blood pressure]]. [[Neuromuscular junction|Neuromuscular]] [[physical examination|examination]] of [[patients]] with [[diabetic foot]] is usually normal, except in their [[foot]]. Altered motor tone, [[Neurological examination|reflexes]] and sensation is expected in these [[patients]]. [[Neuropathy]] [[symptoms]] score (NSS) and [[neuropathy]] disability score (NDS) are helpful in neuropathy assessment of [[patients]] with [[diabetic foot]]. Findings such as impaired [[vibration]] and [[pressure]] perception, [[Proprioception|position sense]] and thresholds for warm thermal perception favor the [[diagnosis]] of [[neuropathy|sensory neuropathy]]. It is critical to check the [[Limb (anatomy)|extremities]] for findings such as [[ulcers]], peeling [[skin]], dilated or [[varicose veins]], shiny [[skin]] with reduced [[hair]] distribution and broken [[nail]] while examining [[diabetic foot]]. Moreover [[infection]] possibility should be evaluated. Findings such as [[pus]], [[erythema]], Warmth, [[induration]] and bad [[odor]] suggest the presence of [[infection]]. In some cases unroofing a small [[scar]] demonstrates a deeper [[infection|infected]] [[abscesses]]. In the other word, evaluating an [[ulcer]] for [[infection]] must be done after debridement. Other necessary [[physical examinations]] in these [[patients]] are checking the [[capillary]] filling time, [[Peripheral arterial disease screening|ankle brachial index]], tactile and vibration [[sensation]] and [[pressure]] perception. | |||
==Physical Examination== | ==Physical Examination== | ||
=== | ===Appearance of the Patient=== | ||
* | *[[Patients]] with [[diabetic foot]] [[ulcer]] could appear ill if [[ulcers]] are severe or infected. | ||
* | ===Vital Signs=== | ||
* | *±[[Fever]] (Based on the [[infection]] severity can present as high or low grade [[fever]]) | ||
* | *[[Hypothermia]] or [[hyperthermia]] may be present | ||
* | *[[Tachycardia]] | ||
* | *Low [[blood pressure]] could be seen in [[sepsis|septic]] [[patients]]. | ||
* | ===Skin=== | ||
* | *[[Skin]] [[physical examination|examination]] of [[patients]] with [[diabetic foot]] is usually normal, except for the [[foot]] [[skin]]. | ||
* | ===HEENT=== | ||
* | *HEENT [[physical examination|examination]] of [[patients]] with [[diabetic foot]] is usually normal. | ||
=== | ===Neck=== | ||
* | *[[Neck]] [[physical examination|examination]] of [[patients]] with [[diabetic foot]] is usually normal. | ||
* | ===Lungs=== | ||
* | *[[Pulmonary]] [[physical examination|examination]] of [[patients]] with [[diabetic foot]] is usually normal. | ||
* | ===Heart=== | ||
* | *[[Circulatory system|Cardiovascular]] [[physical examination|examination]] of [[patients]] with [[diabetic foot]] is usually normal. | ||
=== | ===Abdomen=== | ||
*[[abdomen|Abdominal]] [[physical examination|examination]] of [[patients]] with [[diabetic foot]] is usually normal. | |||
===Back=== | |||
*[[human back|Back]] [[physical examination|examination]] of [[patients]] with [[diabetic foot]] is usually normal. | |||
===Genitourinary=== | |||
*Genitourinary [[physical examination|examination]] of [[patients]] with [[diabetic foot]] is usually normal. | |||
===Neuromuscular=== | |||
*[[Neuromuscular junction|Neuromuscular]] [[physical examination|examination]] of [[patients]] with [[diabetic foot]] is usually normal, except in their [[foot]]. [[physical examination|Examine]] their [[foot]] for the following: | |||
**Motor [[physical examination|examination]] | |||
***Tone | |||
***Power | |||
***[[Neurological examination|Reflexes]] | |||
**Sensory [[physical examination|examination]] | |||
***Vibration | |||
***[[Joint]] position sense | |||
====Neuropathy Assessment==== | |||
The Ipswich Touch Test (IpTT) can diagnosis neuropathy<ref name="pmid34607858">{{cite journal| author=Zhao N, Xu J, Zhou Q, Li X, Chen J, Zhou J | display-authors=etal| title=Application of the Ipswich Touch Test for diabetic peripheral neuropathy screening: a systematic review and meta-analysis. | journal=BMJ Open | year= 2021 | volume= 11 | issue= 10 | pages= e046966 | pmid=34607858 | doi=10.1136/bmjopen-2020-046966 | pmc=8491285 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34607858 }} </ref><ref name="pmid21593300">{{cite journal| author=Rayman G, Vas PR, Baker N, Taylor CG, Gooday C, Alder AI | display-authors=etal| title=The Ipswich Touch Test: a simple and novel method to identify inpatients with diabetes at risk of foot ulceration. | journal=Diabetes Care | year= 2011 | volume= 34 | issue= 7 | pages= 1517-8 | pmid=21593300 | doi=10.2337/dc11-0156 | pmc=3120164 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21593300 }} </ref>. The A [[clinical practice guideline]] by the [https://iwgdfguidelines.org/%20International%20Working%20Group%20on%20the%20Diabetic%20Foot International Working Group on the Diabetic Foot] (IWGDF) recommended the (IpTT) as an alternative to the monofilament exam<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> Instructions for the IpTT are: | |||
:"lightly touch the tips of the first, third and fifth toes of each foot, for 1–2 s, with the tip of the index finger. They were not to push, prod, tap or poke, because this may elicit a sensation other than light touch. With their eyes closed, the patient was instructed to say yes whenever they felt the touch."<ref name="pmid24673517">{{cite journal| author=Sharma S, Kerry C, Atkins H, Rayman G| title=The Ipswich Touch Test: a simple and novel method to screen patients with diabetes at home for increased risk of foot ulceration. | journal=Diabet Med | year= 2014 | volume= 31 | issue= 9 | pages= 1100-3 | pmid=24673517 | doi=10.1111/dme.12450 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24673517 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=25686185 Review in: Ann Intern Med. 2015 Feb 17;162(4):JC10] </ref> | |||
===Sensory=== | The [[neuropathy]] [[symptoms]] score (NSS) and [[neuropathy]] disability score (NDS) are helpful in [[physical examination]] of [[patients]] with [[diabetic foot]].<ref name="pmid12421436">{{cite journal| author=Meijer JW, Smit AJ, Sonderen EV, Groothoff JW, Eisma WH, Links TP| title=Symptom scoring systems to diagnose distal polyneuropathy in diabetes: the Diabetic Neuropathy Symptom score. | journal=Diabet Med | year= 2002 | volume= 19 | issue= 11 | pages= 962-5 | pmid=12421436 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12421436 }} </ref><ref name="pmid15317601">{{cite journal| author=Daousi C, MacFarlane IA, Woodward A, Nurmikko TJ, Bundred PE, Benbow SJ| title=Chronic painful peripheral neuropathy in an urban community: a controlled comparison of people with and without diabetes. | journal=Diabet Med | year= 2004 | volume= 21 | issue= 9 | pages= 976-82 | pmid=15317601 | doi=10.1111/j.1464-5491.2004.01271.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15317601 }} </ref><ref name="pmid22172474">{{cite journal| author=Lepäntalo M, Apelqvist J, Setacci C, Ricco JB, de Donato G, Becker F | display-authors=etal| title=Chapter V: Diabetic foot. | journal=Eur J Vasc Endovasc Surg | year= 2011 | volume= 42 Suppl 2 | issue= | pages= S60-74 | pmid=22172474 | doi=10.1016/S1078-5884(11)60012-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22172474 }} </ref>. Findings that favor the [[diagnosis]] of [[neuropathy|sensory neuropathy]]:<ref name="pmid9531915">{{cite journal| author=Armstrong DG, Lavery LA| title=Diabetic foot ulcers: prevention, diagnosis and classification. | journal=Am Fam Physician | year= 1998 | volume= 57 | issue= 6 | pages= 1325-32, 1337-8 | pmid=9531915 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9531915 }} </ref><ref name="pmid7729300">{{cite journal| author=McNeely MJ, Boyko EJ, Ahroni JH, Stensel VL, Reiber GE, Smith DG | display-authors=etal| title=The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration. How great are the risks? | journal=Diabetes Care | year= 1995 | volume= 18 | issue= 2 | pages= 216-9 | pmid=7729300 | doi=10.2337/diacare.18.2.216 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7729300 }} </ref> | ||
* Vibration | *Impaired [[vibration]] and [[pressure]] perception | ||
* | *Impaired [[Proprioception|position sense]] | ||
*Depressed [[Tendon reflex|tendon reflexes]] | |||
*Dull, crushing or cramp-like [[pain]] in the [[bone|bones]] of the [[feet]] | |||
*Sensory [[ataxia]] | |||
*Shortening of the [[achilles tendon]] | |||
*Abnormal thresholds for warm thermal perception | |||
*Decreased neurovascular function | |||
===Vascular=== | |||
{{See also|Peripheral arterial disease screening}} | |||
*[[pulse|Pulses]] such as [[Dorsalis pedis artery|dorsalis pedis]] and [[Posterior tibial artery|posterior tibial]] [[pulses]] | |||
**Although even when both [[Dorsalis pedis artery|dorsalis pedis]] and [[Posterior tibial artery|posterior tibial]] [[pulses]] are present, low perfusion can not be excluded. | |||
**Note that [[Dorsalis pedis artery|dorsalis pedis]] and [[Posterior tibial artery|posterior tibial]] [[pulses]] are absent in 8% and 3% of normal population, respectively. | |||
*[[Capillary]] filling time (venous refilling > 5s) | |||
The [https://jamanetwork.com/collections/6257/the-rational-clinical-examination Rational Clinical Examination] group concluded<ref name="pmid16449619">{{cite journal| author=Khan NA, Rahim SA, Anand SS, Simel DL, Panju A| title=Does the clinical examination predict lower extremity peripheral arterial disease? | journal=JAMA | year= 2006 | volume= 295 | issue= 5 | pages= 536-46 | pmid=16449619 | doi=10.1001/jama.295.5.536 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16449619 }} </ref>" | |||
* "The [[PAD]] screening score using the hand-held Doppler has the greatest diagnostic accuracy" | |||
** The Score is: | |||
***The number of auscultated components (right posterior tibial artery + left posterior tibial artery; range of 0 for none heard to 3 for normal for each artery)<br/>plus | |||
***The grade of palpated posterior tibial artery (right posterior tibial artery + left posterior tibial artery; 2 for normal, 1 for palpated but abnormal, 0 for not palpable for each artery)<br/>plus | |||
***A history of myocardial infarction (1 for none, 0 for prior myocardial infarction) | |||
** Interpretation: normal is 10 (combining both feet). A score < 6 increases risk of [[PAD]]. | |||
The [[USPSTF]] stated<ref name="pmid29998344">{{cite journal| author=US Preventive Services Task Force. Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB | display-authors=etal| title=Screening for Peripheral Artery Disease and Cardiovascular Disease Risk Assessment With the Ankle-Brachial Index: US Preventive Services Task Force Recommendation Statement. | journal=JAMA | year= 2018 | volume= 320 | issue= 2 | pages= 177-183 | pmid=29998344 | doi=10.1001/jama.2018.8357 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29998344 }} </ref>: | |||
* "The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for PAD and CVD risk with the [[ABI]] in asymptomatic adults. (I statement)." | |||
===Extremities=== | |||
====Inspection==== | |||
The following list is a summary of possible findings in [[diabetic foot]] inspection:<ref name="pmid22172474">{{cite journal| author=Lepäntalo M, Apelqvist J, Setacci C, Ricco JB, de Donato G, Becker F | display-authors=etal| title=Chapter V: Diabetic foot. | journal=Eur J Vasc Endovasc Surg | year= 2011 | volume= 42 Suppl 2 | issue= | pages= S60-74 | pmid=22172474 | doi=10.1016/S1078-5884(11)60012-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22172474 }} </ref><ref name="Wagner1987">{{cite journal|last1=Wagner|first1=F William|title=The Diabetic Foot|journal=Orthopedics|volume=10|issue=1|year=1987|pages=163–172|issn=0147-7447|doi=10.3928/0147-7447-19870101-28}}</ref><ref name="KalishHamdan2010">{{cite journal|last1=Kalish|first1=Jeffrey|last2=Hamdan|first2=Allen|title=Management of diabetic foot problems|journal=Journal of Vascular Surgery|volume=51|issue=2|year=2010|pages=476–486|issn=07415214|doi=10.1016/j.jvs.2009.08.043}}</ref><ref name="pmid7848417">{{cite journal| author=Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW| title=Assessment and management of foot disease in patients with diabetes. | journal=N Engl J Med | year= 1994 | volume= 331 | issue= 13 | pages= 854-60 | pmid=7848417 | doi=10.1056/NEJM199409293311307 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7848417 }} </ref><ref name="pmid23970716">{{cite journal| author=Wukich DK, Armstrong DG, Attinger CE, Boulton AJ, Burns PR, Frykberg RG et al.| title=Inpatient management of diabetic foot disorders: a clinical guide. | journal=Diabetes Care | year= 2013 | volume= 36 | issue= 9 | pages= 2862-71 | pmid=23970716 | doi=10.2337/dc12-2712 | pmc=PMC3747877 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23970716 }} </ref><ref name="pmid22619242">{{cite journal| author=Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG et al.| title=2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. | journal=Clin Infect Dis | year= 2012 | volume= 54 | issue= 12 | pages= e132-73 | pmid=22619242 | doi=10.1093/cid/cis346 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22619242 }} </ref> | |||
*Peeling [[skin]], [[maceration]], [[fissure|fissuring]] between [[toe|toes]] | |||
*Dilated or [[varicose veins]] | |||
*[[Scar]] | |||
*Sinuses | |||
*Shiny [[skin]] | |||
*Decreased [[hair]] distribution | |||
*Areas of [[Biological pigment|pigmentation]] or discoloration | |||
*[[Ulcers]] | |||
**[[Ulcers]] in the areas under pressure such as base of the [[toe]] or the fifth [[metatarsus]] and posterior aspect of heel. | |||
*Brittle or broken [[nail]] | |||
*[[Infection]] | |||
**Such as [[fungi|fungal]] [[infection]] | |||
**Presence of [[pus]] (thick, opaque to white or sanguineous [[secretion]]) or at least two of the following is indicative of [[infection]]: | |||
***[[Erythema|Redness]] ([[Erythema]]) | |||
***[[Pain]] and local [[tenderness]] | |||
***Warmth | |||
***Delayed [[wound healing]] | |||
***[[edema|Swelling]] or [[induration]] | |||
***Bad [[odor]] | |||
**In some cases unroofing a small [[scar]] demonstrates a deeper [[infection|infected]] [[abscesses]]. In the other word, evaluating an [[ulcer]] for [[infection]] must be done after debridement. | |||
**The following are some of the findings that indicate a [[Limb (anatomy)|limb]] threatening [[infection]]: | |||
***[[Cellulitis]] extension more than 2 cm from the [[ulcer]]'s margin | |||
***Deep [[abscesses]] | |||
***[[Osteomyelitis]] | |||
***Severe [[ischemia]] | |||
*[[Foot]] deformities such as [[charcot joint|charcot foot]] and [[hammer toe]] | |||
*Pink [[skin]] | |||
**Even in [[ischemia|ischemic settings]] due to [[Shunt (medical)|arteriovenous shunting]]. | |||
====Palpation==== | |||
The following is a list of recommended examinations in a [[diabetic foot]] [[patients]]:<ref name="pmid22172474">{{cite journal| author=Lepäntalo M, Apelqvist J, Setacci C, Ricco JB, de Donato G, Becker F | display-authors=etal| title=Chapter V: Diabetic foot. | journal=Eur J Vasc Endovasc Surg | year= 2011 | volume= 42 Suppl 2 | issue= | pages= S60-74 | pmid=22172474 | doi=10.1016/S1078-5884(11)60012-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22172474 }} </ref><ref name="pmid7729300">{{cite journal| author=McNeely MJ, Boyko EJ, Ahroni JH, Stensel VL, Reiber GE, Smith DG | display-authors=etal| title=The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration. How great are the risks? | journal=Diabetes Care | year= 1995 | volume= 18 | issue= 2 | pages= 216-9 | pmid=7729300 | doi=10.2337/diacare.18.2.216 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7729300 }} </ref><ref name="pmid7853630">{{cite journal| author=Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW| title=Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients. | journal=JAMA | year= 1995 | volume= 273 | issue= 9 | pages= 721-3 | pmid=7853630 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7853630 }} </ref> | |||
*Temperature | |||
*Increased temperature could be due to [[deep vein thrombosis]] while decreased temperature could be an [[ischemia]] presentation. | |||
*Due to [[shunt (medicine)|arteriovenous shunting]] the involved area may feel warm even in presence of [[ischemia]]. | |||
*[[Tenderness]] (squeeze [[Tibia|calf]] [[muscle]] and [[achilles tendon]] for [[tenderness]]) | |||
*[[pulse|Pulses]] such as [[Dorsalis pedis artery|dorsalis pedis]] and [[Posterior tibial artery|posterior tibial]] [[pulses]] | |||
**Although even when both [[Dorsalis pedis artery|dorsalis pedis]] and [[Posterior tibial artery|posterior tibial]] [[pulses]] are present, low perfusion can not be excluded. | |||
**Note that [[Dorsalis pedis artery|dorsalis pedis]] and [[Posterior tibial artery|posterior tibial]] [[pulses]] are absent in 8% and 3% of normal population, respectively. | |||
*[[Capillary]] filling time (venous refilling > 5s) | |||
*[[Muscle strength]] and tone | |||
*Check [[Peripheral arterial disease screening|ankle brachial index]] ([[Peripheral arterial disease screening|ABI]]) | |||
*Pinprick discrimination and tactile [[sensation]] test (use a cotton wool to examine) | |||
*Vibration test (use a 128 Hz-tuning fork) | |||
*Pressure perception test (use a 10-gram (5.07) Semmes––Weinstein monofilament) | |||
**Single most practical method to assess risks for [[diabetic foot]] such as [[neuropathy]] | |||
*Quantitative sensory testing and autonomic testing | |||
*Probing | |||
**Using a blunted sterile probe will help [[physicians]] to determine [[ulcer]]'s margins, sinus tract development and involvement of [[tendons]], [[bone|bones]] or [[joints]]. | |||
**Positive probe-to-[[bone]] is strongly correlated with [[osteomyelitis]]. | |||
===Video: Physical Examination Diabetes=== | |||
{{#ev:youtube|715j6zRZHaA}} | |||
===Image: Diabetic Foot Ulcer=== | |||
[[Image:Diabetic foot ulcer.jpg|400px|left|Diabetic foot ulcer]] | |||
<br clear="left"/> | |||
==Staging of diabetic wounds== | |||
A systematic review identified better staging systems<ref name="pmid20536950">{{cite journal| author=Karthikesalingam A, Holt PJ, Moxey P, Jones KG, Thompson MM, Hinchliffe RJ| title=A systematic review of scoring systems for diabetic foot ulcers. | journal=Diabet Med | year= 2010 | volume= 27 | issue= 5 | pages= 544-9 | pmid=20536950 | doi=10.1111/j.1464-5491.2010.02989.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20536950 }} </ref>: | |||
* University of Texas (UT) Score<ref name="pmid8986890">{{cite journal| author=Lavery LA, Armstrong DG, Harkless LB| title=Classification of diabetic foot wounds. | journal=J Foot Ankle Surg | year= 1996 | volume= 35 | issue= 6 | pages= 528-31 | pmid=8986890 | doi=10.1016/s1067-2516(96)80125-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8986890 }} </ref> | |||
More recently, the International Working Group’s diabetic foot (IWGDF) risk classification <ref name="LaveryArmstrong2012">{{cite book | title = The Diabetic Foot | last1 = Lavery | first1 = Lawrence A. | last2 = Armstrong | first2 = David G. | chapter = Clinical Examination and Risk Classification of the Diabetic Foot | date = 2012 | pages = 59–74 | publisher = Humana Press | doi = 10.1007/978-1-61779-791-0_4 | url = http://www.egradu.fmed.edu.uy/sites/www.dbc.fmed.edu.uy/files/Residentes/Archivospar/PIE%20DIABETICO%201.pdf}}</ref>. | |||
{| class="wikitable" | |||
|- | |||
|+International Working Group’s diabetic foot (IWGDF) risk classification <ref name="LaveryArmstrong2012">{{cite book | title = The Diabetic Foot | last1 = Lavery | first1 = Lawrence A. | last2 = Armstrong | first2 = David G. | chapter = Clinical Examination and Risk Classification of the Diabetic Foot | date = 2012 | pages = 59–74 | publisher = Humana Press | doi = 10.1007/978-1-61779-791-0_4 | url = }}</ref> | |||
|- | |||
! Risk group | |||
! Findings | |||
|- | |||
| Risk Group 0 | |||
| No neuropathy<br />No peripheral arterial<br />No foot deformity or limited joint mobility | |||
|- | |||
| Risk Group 1 | |||
| Peripheral neuropathy<br />No peripheral arterial<br />No foot deformity or limited joint mobility | |||
|- | |||
| Risk Group 2 | |||
| Peripheral neuropathy and foot deformity or limited joint mobility<br />and/or peripheral arterial disease | |||
|- | |||
| Risk Group 3 | |||
| History of ulcer or amputation or Charcot | |||
|} | |||
The working group separately describes the UT classification of ulcers. This system includes "preulcerative" lesions: | |||
* "Grade 0 wounds are preulcerative areas or previous ulcer sites that are now completely epithelialized after debridement of hyperkeratosis and nonviable tissue. The diagnosis of a Grade 0 wound can be made only after removal of any regional hyperkeratosis, as quite often frank ulcerations may be hidden by overlying calluses" | |||
* The system adds whether the lesion is associated with infection or ischemia. | |||
==References== | ==References== | ||
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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] Vishnu Vardhan Serla M.B.B.S. [3]
Overview
Patients with diabetic foot ulcer could appear ill if ulcers are severe or infected. In severe and chronic infected ulcers patients may have fever, tachycardia and low blood pressure. Neuromuscular examination of patients with diabetic foot is usually normal, except in their foot. Altered motor tone, reflexes and sensation is expected in these patients. Neuropathy symptoms score (NSS) and neuropathy disability score (NDS) are helpful in neuropathy assessment of patients with diabetic foot. Findings such as impaired vibration and pressure perception, position sense and thresholds for warm thermal perception favor the diagnosis of sensory neuropathy. It is critical to check the extremities for findings such as ulcers, peeling skin, dilated or varicose veins, shiny skin with reduced hair distribution and broken nail while examining diabetic foot. Moreover infection possibility should be evaluated. Findings such as pus, erythema, Warmth, induration and bad odor suggest the presence of infection. In some cases unroofing a small scar demonstrates a deeper infected abscesses. In the other word, evaluating an ulcer for infection must be done after debridement. Other necessary physical examinations in these patients are checking the capillary filling time, ankle brachial index, tactile and vibration sensation and pressure perception.
Physical Examination
Appearance of the Patient
- Patients with diabetic foot ulcer could appear ill if ulcers are severe or infected.
Vital Signs
- ±Fever (Based on the infection severity can present as high or low grade fever)
- Hypothermia or hyperthermia may be present
- Tachycardia
- Low blood pressure could be seen in septic patients.
Skin
- Skin examination of patients with diabetic foot is usually normal, except for the foot skin.
HEENT
- HEENT examination of patients with diabetic foot is usually normal.
Neck
- Neck examination of patients with diabetic foot is usually normal.
Lungs
- Pulmonary examination of patients with diabetic foot is usually normal.
Heart
- Cardiovascular examination of patients with diabetic foot is usually normal.
Abdomen
- Abdominal examination of patients with diabetic foot is usually normal.
Back
- Back examination of patients with diabetic foot is usually normal.
Genitourinary
- Genitourinary examination of patients with diabetic foot is usually normal.
Neuromuscular
- Neuromuscular examination of patients with diabetic foot is usually normal, except in their foot. Examine their foot for the following:
- Motor examination
- Tone
- Power
- Reflexes
- Sensory examination
- Vibration
- Joint position sense
- Motor examination
Neuropathy Assessment
The Ipswich Touch Test (IpTT) can diagnosis neuropathy[1][2]. The A clinical practice guideline by the International Working Group on the Diabetic Foot (IWGDF) recommended the (IpTT) as an alternative to the monofilament exam[3] Instructions for the IpTT are:
- "lightly touch the tips of the first, third and fifth toes of each foot, for 1–2 s, with the tip of the index finger. They were not to push, prod, tap or poke, because this may elicit a sensation other than light touch. With their eyes closed, the patient was instructed to say yes whenever they felt the touch."[4]
The neuropathy symptoms score (NSS) and neuropathy disability score (NDS) are helpful in physical examination of patients with diabetic foot.[5][6][7]. Findings that favor the diagnosis of sensory neuropathy:[8][9]
- Impaired vibration and pressure perception
- Impaired position sense
- Depressed tendon reflexes
- Dull, crushing or cramp-like pain in the bones of the feet
- Sensory ataxia
- Shortening of the achilles tendon
- Abnormal thresholds for warm thermal perception
- Decreased neurovascular function
Vascular
- Pulses such as dorsalis pedis and posterior tibial pulses
- Although even when both dorsalis pedis and posterior tibial pulses are present, low perfusion can not be excluded.
- Note that dorsalis pedis and posterior tibial pulses are absent in 8% and 3% of normal population, respectively.
- Capillary filling time (venous refilling > 5s)
The Rational Clinical Examination group concluded[10]"
- "The PAD screening score using the hand-held Doppler has the greatest diagnostic accuracy"
- The Score is:
- The number of auscultated components (right posterior tibial artery + left posterior tibial artery; range of 0 for none heard to 3 for normal for each artery)
plus - The grade of palpated posterior tibial artery (right posterior tibial artery + left posterior tibial artery; 2 for normal, 1 for palpated but abnormal, 0 for not palpable for each artery)
plus - A history of myocardial infarction (1 for none, 0 for prior myocardial infarction)
- The number of auscultated components (right posterior tibial artery + left posterior tibial artery; range of 0 for none heard to 3 for normal for each artery)
- Interpretation: normal is 10 (combining both feet). A score < 6 increases risk of PAD.
- The Score is:
- "The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for PAD and CVD risk with the ABI in asymptomatic adults. (I statement)."
Extremities
Inspection
The following list is a summary of possible findings in diabetic foot inspection:[7][12][13][14][15][16]
- Peeling skin, maceration, fissuring between toes
- Dilated or varicose veins
- Scar
- Sinuses
- Shiny skin
- Decreased hair distribution
- Areas of pigmentation or discoloration
- Ulcers
- Ulcers in the areas under pressure such as base of the toe or the fifth metatarsus and posterior aspect of heel.
- Brittle or broken nail
- Infection
- Such as fungal infection
- Presence of pus (thick, opaque to white or sanguineous secretion) or at least two of the following is indicative of infection:
- Redness (Erythema)
- Pain and local tenderness
- Warmth
- Delayed wound healing
- Swelling or induration
- Bad odor
- In some cases unroofing a small scar demonstrates a deeper infected abscesses. In the other word, evaluating an ulcer for infection must be done after debridement.
- The following are some of the findings that indicate a limb threatening infection:
- Cellulitis extension more than 2 cm from the ulcer's margin
- Deep abscesses
- Osteomyelitis
- Severe ischemia
- Foot deformities such as charcot foot and hammer toe
- Pink skin
- Even in ischemic settings due to arteriovenous shunting.
Palpation
The following is a list of recommended examinations in a diabetic foot patients:[7][9][17]
- Temperature
- Increased temperature could be due to deep vein thrombosis while decreased temperature could be an ischemia presentation.
- Due to arteriovenous shunting the involved area may feel warm even in presence of ischemia.
- Tenderness (squeeze calf muscle and achilles tendon for tenderness)
- Pulses such as dorsalis pedis and posterior tibial pulses
- Although even when both dorsalis pedis and posterior tibial pulses are present, low perfusion can not be excluded.
- Note that dorsalis pedis and posterior tibial pulses are absent in 8% and 3% of normal population, respectively.
- Capillary filling time (venous refilling > 5s)
- Muscle strength and tone
- Check ankle brachial index (ABI)
- Pinprick discrimination and tactile sensation test (use a cotton wool to examine)
- Vibration test (use a 128 Hz-tuning fork)
- Pressure perception test (use a 10-gram (5.07) Semmes––Weinstein monofilament)
- Single most practical method to assess risks for diabetic foot such as neuropathy
- Quantitative sensory testing and autonomic testing
- Probing
- Using a blunted sterile probe will help physicians to determine ulcer's margins, sinus tract development and involvement of tendons, bones or joints.
- Positive probe-to-bone is strongly correlated with osteomyelitis.
Video: Physical Examination Diabetes
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Image: Diabetic Foot Ulcer
![Diabetic foot ulcer](/images/d/d0/Diabetic_foot_ulcer.jpg)
Staging of diabetic wounds
A systematic review identified better staging systems[18]:
- University of Texas (UT) Score[19]
More recently, the International Working Group’s diabetic foot (IWGDF) risk classification [20].
Risk group | Findings |
---|---|
Risk Group 0 | No neuropathy No peripheral arterial No foot deformity or limited joint mobility |
Risk Group 1 | Peripheral neuropathy No peripheral arterial No foot deformity or limited joint mobility |
Risk Group 2 | Peripheral neuropathy and foot deformity or limited joint mobility and/or peripheral arterial disease |
Risk Group 3 | History of ulcer or amputation or Charcot |
The working group separately describes the UT classification of ulcers. This system includes "preulcerative" lesions:
- "Grade 0 wounds are preulcerative areas or previous ulcer sites that are now completely epithelialized after debridement of hyperkeratosis and nonviable tissue. The diagnosis of a Grade 0 wound can be made only after removal of any regional hyperkeratosis, as quite often frank ulcerations may be hidden by overlying calluses"
- The system adds whether the lesion is associated with infection or ischemia.
References
- ↑ Zhao N, Xu J, Zhou Q, Li X, Chen J, Zhou J; et al. (2021). "Application of the Ipswich Touch Test for diabetic peripheral neuropathy screening: a systematic review and meta-analysis". BMJ Open. 11 (10): e046966. doi:10.1136/bmjopen-2020-046966. PMC 8491285 Check
|pmc=
value (help). PMID 34607858 Check|pmid=
value (help). - ↑ Rayman G, Vas PR, Baker N, Taylor CG, Gooday C, Alder AI; et al. (2011). "The Ipswich Touch Test: a simple and novel method to identify inpatients with diabetes at risk of foot ulceration". Diabetes Care. 34 (7): 1517–8. doi:10.2337/dc11-0156. PMC 3120164. PMID 21593300.
- ↑ 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). - ↑ Sharma S, Kerry C, Atkins H, Rayman G (2014). "The Ipswich Touch Test: a simple and novel method to screen patients with diabetes at home for increased risk of foot ulceration". Diabet Med. 31 (9): 1100–3. doi:10.1111/dme.12450. PMID 24673517. Review in: Ann Intern Med. 2015 Feb 17;162(4):JC10
- ↑ Meijer JW, Smit AJ, Sonderen EV, Groothoff JW, Eisma WH, Links TP (2002). "Symptom scoring systems to diagnose distal polyneuropathy in diabetes: the Diabetic Neuropathy Symptom score". Diabet Med. 19 (11): 962–5. PMID 12421436.
- ↑ Daousi C, MacFarlane IA, Woodward A, Nurmikko TJ, Bundred PE, Benbow SJ (2004). "Chronic painful peripheral neuropathy in an urban community: a controlled comparison of people with and without diabetes". Diabet Med. 21 (9): 976–82. doi:10.1111/j.1464-5491.2004.01271.x. PMID 15317601.
- ↑ 7.0 7.1 7.2 Lepäntalo M, Apelqvist J, Setacci C, Ricco JB, de Donato G, Becker F; et al. (2011). "Chapter V: Diabetic foot". Eur J Vasc Endovasc Surg. 42 Suppl 2: S60–74. doi:10.1016/S1078-5884(11)60012-9. PMID 22172474.
- ↑ Armstrong DG, Lavery LA (1998). "Diabetic foot ulcers: prevention, diagnosis and classification". Am Fam Physician. 57 (6): 1325–32, 1337–8. PMID 9531915.
- ↑ 9.0 9.1 McNeely MJ, Boyko EJ, Ahroni JH, Stensel VL, Reiber GE, Smith DG; et al. (1995). "The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration. How great are the risks?". Diabetes Care. 18 (2): 216–9. doi:10.2337/diacare.18.2.216. PMID 7729300.
- ↑ Khan NA, Rahim SA, Anand SS, Simel DL, Panju A (2006). "Does the clinical examination predict lower extremity peripheral arterial disease?". JAMA. 295 (5): 536–46. doi:10.1001/jama.295.5.536. PMID 16449619.
- ↑ US Preventive Services Task Force. Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB; et al. (2018). "Screening for Peripheral Artery Disease and Cardiovascular Disease Risk Assessment With the Ankle-Brachial Index: US Preventive Services Task Force Recommendation Statement". JAMA. 320 (2): 177–183. doi:10.1001/jama.2018.8357. PMID 29998344.
- ↑ Wagner, F William (1987). "The Diabetic Foot". Orthopedics. 10 (1): 163–172. doi:10.3928/0147-7447-19870101-28. ISSN 0147-7447.
- ↑ Kalish, Jeffrey; Hamdan, Allen (2010). "Management of diabetic foot problems". Journal of Vascular Surgery. 51 (2): 476–486. doi:10.1016/j.jvs.2009.08.043. ISSN 0741-5214.
- ↑ Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW (1994). "Assessment and management of foot disease in patients with diabetes". N Engl J Med. 331 (13): 854–60. doi:10.1056/NEJM199409293311307. PMID 7848417.
- ↑ Wukich DK, Armstrong DG, Attinger CE, Boulton AJ, Burns PR, Frykberg RG; et al. (2013). "Inpatient management of diabetic foot disorders: a clinical guide". Diabetes Care. 36 (9): 2862–71. doi:10.2337/dc12-2712. PMC 3747877. PMID 23970716.
- ↑ Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG; et al. (2012). "2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections". Clin Infect Dis. 54 (12): e132–73. doi:10.1093/cid/cis346. PMID 22619242.
- ↑ Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW (1995). "Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients". JAMA. 273 (9): 721–3. PMID 7853630.
- ↑ Karthikesalingam A, Holt PJ, Moxey P, Jones KG, Thompson MM, Hinchliffe RJ (2010). "A systematic review of scoring systems for diabetic foot ulcers". Diabet Med. 27 (5): 544–9. doi:10.1111/j.1464-5491.2010.02989.x. PMID 20536950.
- ↑ Lavery LA, Armstrong DG, Harkless LB (1996). "Classification of diabetic foot wounds". J Foot Ankle Surg. 35 (6): 528–31. doi:10.1016/s1067-2516(96)80125-6. PMID 8986890.
- ↑ 20.0 20.1 Lavery, Lawrence A.; Armstrong, David G. (2012). "Clinical Examination and Risk Classification of the Diabetic Foot". The Diabetic Foot (PDF). Humana Press. pp. 59–74. doi:10.1007/978-1-61779-791-0_4.