A simple protocol can assess the diabetic foot for the presence of predisposing factors for ulcerations and amputation, and can be used to guide treatment, according to recommendations developed by an American Diabetes Association task force.
The protocol consists of a history, general examination, and an assessment of dermatologic, musculoskeletal, neurologic, and vascular factors. Details of the protocol were issued by the American Diabetes Association, with the endorsement of the American Association of Clinical Endocrinologists, in a report by Dr. Andrew J. M. Boulton and his colleagues in a task force of the ADA's Foot Care Interest Group.
The history should explore previous foot ulceration or amputation, neuropathic or peripheral vascular symptoms, impaired vision, renal replacement therapy, and tobacco use.
Key components of the diabetic foot exam include dermatologic inspection for skin status, sweating, infection, ulceration, and calluses, as well as musculoskeletal inspection for deformity (claw toes, prominent metatarsal heads, Charcot's joint) or muscle wasting.
Neurologic assessment for loss of protective sensation (LOPS) should include the use of a 10-g monofilament test, with the device placed at specific points on the bottom of the foot while the patient's eyes are closed, as well as one of these additional tests:
▸ Vibration with 128-Hz tuning fork.
▸ Pinprick sensation.
▸ Ankle reflexes.
▸ Vibration perception threshold testing.
Vascular assessment using ankle brachial pressure index testing should be performed to determine the presence of peripheral arterial disease (PAD) in two groups of patients: those who are symptomatic (claudication, rest pain, or nonhealing ulcer) and those who have absent posterior tibial or dorsalis pedis pulses (Diabetes Care 2008;31:1679–85).
Patients assessed using the protocol should be assigned to a foot risk category from 0 to 3, with 0 being no LOPS, no PAD, and no deformity, 1 being LOPS with or without deformity, 2 being PAD with or without LOPS, and 3 being a history of ulcer or amputation.
Subsequent therapy and follow-up care should be provided according to the category: Primary care monitoring is appropriate for risk categories 0 and 1, and specialist care is indicated for risk categories 2 and 3.