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Diabetic foot examination frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. This guide provides a clear step by step approach to examining diabetic feet, with an included video demonstration.

Check out the diabetic foot examination mark scheme here.


Introduction

Wash hands

Introduce yourself

Confirm patient details – name / DOB

Explain the examination

Gain consent

Position patient on an examination couch at 45°

Expose patient’s lower legs and feet


Gather equipment

  • Monofilament
  • Tuning fork (128 Hz)
  • Tendon hammer

Inspection

Inspect legs and feet thoroughly (make sure to inspect the posterior aspects of the legs and between the toes)

Colour – pallor / cyanosis /erythema (e.g.ischaemia / cellulitis)

Skin:

  • Dry / shiny / hair loss – peripheral vascular disease (PVD)
  • Eczema / haemosiderin staining – venous disease

 

Ulcers – inspect limbs thoroughly (including posterior aspects and between toes)

  • Venous ulcers – moderate to no pain – larger /shallow – associated with venous insufficiency / varicose veins
  • Arterial ulcers  – very painful – deep punched out appearance – associated with diabetes mellitus / peripheral vascular disease

 

Swelling:

  • Oedema – e.g. venous insufficiency / heart failure
  • Deep vein thrombosis  – tender on palpation

 

Calluses – may indicate incorrectly fitting shoes

Venous filling – guttering of veins / reduced visibility suggests PVD

Deformity caused by neuropathy (e.g. Charcot arthropathy)

  • Peripheral vascular examination
    Inspect legs for hair loss / skin changes

Palpation

Temperature – cool (e.g. PVD) / hot (e.g. cellulitis)

Capillary refill time – normal: < 2 seconds – prolongation suggests PVD

Pulses:

  • Dorsalis pedis artery – lateral to extensor hallucis longus tendon
  • Posterior tibial artery – posterior and inferior to medial malleolus 

Absence of peripheral pulses is suggestive of peripheral vascular disease.

  • Leg temperature
    Assess & compare leg temperature

Sensation

Monofilament

1. Provide an example of monofilament sensation on the patient’s arm or sternum

2. With the patient’s eyes closed, place monofilament on the hallux and metatarsal heads (1st/2nd/3rd/5th)

3. Press firmly so that the filament bends

4. Hold the monofilament against the skin for 1-2 seconds – ask patient to say when they feel it

Avoid calluses and scars as they will likely have a reduced level of sensation which is not representative of the surrounding normal tissue.

  • Correct Monofilament locations
    Locations to place monofilament

Vibration sensation

1. Ask the patient to close their eyes

2. Tap a 128 Hz tuning fork

3. Place onto the patient’s sternum and confirm the patient can feel it buzzing

4. Ask the patient to tell you when they can feel it on their foot and to tell you when it stops buzzing

5. Assess sensation by placing the vibrating tuning fork onto the distal phalanx of the great toe (repeat assessment on the other leg)

6. If sensation is intact the patient should state that they can feel the tuning fork buzzing

7. You should then gently place your hand onto the tuning fork to stop it vibrating, if the patient’s sensation is intact then they should state that the vibration has now stopped

8. If sensation is impaired, continue to assess more proximally – e.g. proximal phalanx

9. Repeat assessment on the other leg

  • Vibration sensation
    Assess vibration sensation

Gait

Observe the patient walking whilst assessing:

  • Symmetry / balance
  • Turning – quick / slow / staggered
  • Abnormalities – broad based gait / foot drop / antalgia

 

Examine the footwear:

  • Note pattern of wear on soles – asymmetrical wearing – gait abnormality
  • Ensure the shoes are the correct size for the patient
  • Note holes and material inside the shoes that could cause foot injury
  • Gait Cycle
    Assess GAIT

Other tests to consider

If abnormalities in monofilament or vibration sensation are identified, consider carrying out the further tests shown below.

Proprioception

1. Hold the distal phalanx of the great toe by its sides

2. Demonstrate movement of the toe “upwards” and “downwards” to the patient (whilst they watch)

3. Then ask patient to close their eyes and state if you are moving the toe up or down

4. If the patient is unable to correctly identify direction of movement, move to a more proximal joint ( ankle > knee > hip)

  • Proprioception
    Assess proprioception

Ankle jerk reflex

1. Dorsiflex the foot

2. Tap tendon hammer over the Achilles tendon

3. Observe the calf for contraction – normal reflex

Ankle jerk reflex may be absent in advanced peripheral neuropathy.

  • Ankle jerk reflex
    Assess ankle jerk reflex

To complete the examination

Thank patient

Wash hands

 

Suggest further assessments, advice and investigations


REVIEWED BY

Dr Simon Ashwell

Consultant endocrinologist


 

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