COMMENTARY

A 3-Minute Screening Exam for Diabetic Foot

David G. Armstrong, DPM, MD, PhD; Brian D. Lepow, DPM

Disclosures

January 04, 2016

About 30 million Americans are living with diabetes,[1] and about 15% of them eventually will develop a foot ulcer, with 2- to 5-year recurrence rates exceeding 50%. Alarmingly, 15%-24% of recurrent ulcerations lead to amputations.[2]

As the diabetic population grows, so does the demand for a more streamlined screening protocol for the diabetic foot. Such a protocol should expedite referrals, with the hope of getting patients to a specialist before they face hospitalization or a preventable amputation.

The primary care provider (PCP) is the front-line defender against complications of diabetes, including the diabetic foot. Unfortunately, the shortfall of PCPs is projected to grow even as the number of patients with diabetes increases, raising the burden of screening and referral and leaving even less time for health education and prevention.[3,4]

The routine foot exam and rapid risk stratification is often difficult to incorporate into an already busy primary care exam. Data suggest that the diabetic foot is adequately evaluated in only 12%-20% of patient encounters.[5]

The "3-minute foot exam" was designed to provide healthcare providers with a thorough yet concise and easily repeatable way to evaluate the lower extremity of the diabetic patient. This exam consists of three components, each performed in 1 minute or less: a patient history, a physical exam, and patient education.

Patient History

A complete medical history can help identify certain factors that may increase the risk for the patient to develop a lower-extremity complication. Asking diabetic patients about glucose control and history of lower-extremity conditions, such as wounds or amputations, is crucial when screening for diabetic foot.

Patients with previous lower-extremity ulceration or amputation carry a 60% greater risk for reulceration.[2,6] It is also important to inquire about previous vascular procedures and the patient's use of tobacco, which is linked to peripheral artery disease.[7]

Physical Examination

The physical exam should include a careful examination of the feet in every patient with suspected or confirmed diabetes. One should inspect the musculoskeletal system, perform a neurological exam, assess the vascular status of the lower extremity, and evaluate the dermatologic condition of the patient's lower extremity. Up to 50% of patients may be asymptomatic owing to loss of protective sensation (LOPS).[8] Failure to identify any problems early can result in detrimental consequences, including hospitalization and amputation.

Essential components of the physical examination for diabetic foot include orthopedic/musculoskeletal, neurologic, vascular, and dermatologic examinations. Including all these systems may sound daunting, but with practice, the provider will be able to accomplish the diabetic foot examination quickly and thoroughly.

Orthopedic/Musculoskeletal Examination

This portion of the exam should focus on any biomechanical abnormalities of the foot and ankle, including deformities, such as bunions, hammertoes, and enlarged bony prominences. Limitation or restriction in range of motion of any joint in the foot and ankle can significantly increase the risk for ulceration.[9]

Muscle strength should also be evaluated to assess weakness and asymmetry. Musculoskeletal abnormalities of the foot and ankle can lead to problems with properly fitting shoe gear as well as mobility, and contribute to a higher risk for injury.[10]

Neurologic Examination

The neurologic portion of the exam should focus on the presence or absence of protective sensation. LOPS has been linked to 75% of all nontraumatic diabetic foot-related amputations.[11,12,13,14] LOPS can lead to diminished skin integrity and musculoskeletal imbalance, and can increase the risk for ulceration.

Various devices exist to test for LOPS and include vibratory perception threshold devices,[15] Semmes-Weinstein monofilaments,[16] and 128-Hz tuning forks.[6] Unfortunately, these devices are not always readily available to the PCP.

The Ipswich Touch Test (IpTT) is an alternative neurologic test that requires only the examiner's index finger.[17] The IpTT is performed by asking the patient to close his or her eyes while the examiner lightly places an index finger on the patient's first, third, and fifth toes for 2 seconds. The patient is instructed to respond "yes" when they feel the examiner's touch. This method has been found to be as sensitive and specific as Semmes-Weinstein monofilaments for detecting LOPS[18] and does not require the use of any specific device.

Vascular Examination

This portion of the exam includes a bilateral assessment by palpation of the femoral, popliteal, posterior tibial, and dorsalis pedis pulses. A diminished or absent pulse could serve as an indicator of a more serious underlying problem of vascular compromise.[19,20]

Substantial data show that compromised circulation leads to the development of impaired healing in up to one half of all foot ulcerations in patients with diabetes.[7,21,22,23,24,25] Skin temperature, digital hair growth, capillary refill times, and edema of both lower extremities should also be evaluated and compared. Abnormal findings can also indicate the presence of peripheral artery disease.

Dermatologic Examination

The dermatologic exam includes a comprehensive inspection of the skin for abnormal integrity, including dryness, cracking, discoloration, and callous formation, which are probable precursors to ulceration. An abnormal finding should prompt an expedited referral to the specialist for further evaluation and treatment.[6,21,26,27,28]

The PCP should also inspect the toes for the presence of thickened, elongated, or ingrowing nails, and check between the toes for any skin maceration or tears, which can be easily missed and lead to detrimental consequences.

Patient Education

Education is power when it comes to helping at risk patients understand their condition and involving them in their care. The lack of appropriate education about diabetes has been found to increase recurrent ulcer risk by 90%.[29] Education regarding appropriate foot hygiene, skin and nail care, and the use of proper foot wear can help reduce injuries that may lead to foot ulceration.[30]

Patient education improves knowledge about these complications and may modestly reduce the risk for foot ulcerations and amputations in the short term.[31,32] More data are needed to determine the long-term benefits of the types of education that are most helpful to the patient.

Upon completion of the 3-minute foot examination, the PCP should have a firm understanding of the patient's needs and should be able to triage the patient's treatment and follow up appropriately. The examination will also help guide the necessary referral to a specialist who can best deal with the pathology and ensure successful outcomes of the treatments.

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