Diabetic foot screening
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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
- 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, anatomical deformities, nail changes and distal pulses should not be omitted during foot examination.[1][2][3]
- A regular foot examination should be done in diabetic patients, in order to detect peripheral neuropathy, peripheral arterial disease and anatomical foot deformities.[4]
- It is recommended to perform a careful foot examination at least annually in diabetic patients over the age of 15. Nevertheless, physicians should educate patients to perform self foot examinations more often.
- In diabetic patients who have higher risk of diabetic foot ulceration, more frequent (every 1-6 months) 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 diabetic patients with high risk of foot ulceration. The aforementioned guideline includes a scoring system which clarifies the proper intervals for screening diabetic patients. The following table is a summary of this system:[5][6]
| 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 |
- One of the IWGDF guidelines on the management and 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:[7]
| 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 |
- The following are some useful screening tools for diabetic foot screening:[8][9][10][11]
- Semmes-Weinstein monofilament
- Tuning fork
- Biothesiometer
References
- ↑ 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.
- ↑ 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.
- ↑ Mishra SC, Chhatbar KC, Kashikar A, Mehndiratta A (2017). "Diabetic foot". BMJ. 359: j5064. doi:10.1136/bmj.j5064. PMC 5688746. PMID 29146579.
- ↑ 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.
- ↑ 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). - ↑ 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). - ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.