Reviews/Commentaries/ADA Statements

T A S K F O R C E R E P O R T

Comprehensive Foot Examination and Risk

Assessment
A report of the Task Force of the Foot Care Interest Group of the
American Diabetes Association, with endorsement by the American
Association of Clinical Endocrinologists
1,2
ANDREW J.M. BOULTON, MD, FRCP LAWRENCE A. LAVERY, DPM, MPH
9
foot problems is the first step in prevent-
DAVID G. ARMSTRONG, DPM, PHD3 JOSEPH W. LEMASTER, MD, MPH10 ing such complications, this report will
STEPHEN F. ALBERT, DPM, CPED4 JOSEPH L. MILLS, SR., MD11 12 focus on key components of the foot
ROBERT G. FRYKBERG, DPM, MPH5 MICHAEL J. MUELLER, PT, PH
RICHARD HELLMAN, MD, 6,7 exam.
8
FACP PETER SHEEHAN, MD13 14 D
M. SUE KIRKMAN, MD DANE K. WUKICH, MD
COMPONENTS OF THE
FOOT EXAM
t is now 10 years since the last surgery, and the American Association of

I
technical review on preventative foot Clinical Endocrinologists. History
care was published (1), which was While history is a pivotal component of
followed by risk assessment, a patient cannot be fully
THE PATHWAY TO FOOT
an American Diabetes Association assessed for risk factors for foot ulceration
ULCERATION
(ADA) position statement on preventive based on history alone; a careful foot
The lifetime risk of a person with
foot care in diabetes (2). Many studies exam remains the key component of this
diabetes developing a foot ulcer may be
have been published proposing a range as high as process. Key components of the history
of tests that might usefully identify 25%, whereas the annual incidence of include previous foot ulceration or
patients at risk of foot ulceration, foot ulcers is 2% (3–7). Up to 50% of ampu- tation. Other important
creating confusion among practitioners older patients with type 2 diabetes have assessments in the history (Table 2)
as to which screening tests should be one or more risk factors for foot include neuropathic or peripheral
adopted in clinical practice. A task force ulceration (3,6). A number of vascular symptoms (7,8), impaired
was therefore assembled by the ADA to component causes, most importantly vision, or renal replacement therapy.
address and concisely summarize recent peripheral neuropathy, interact to Lastly, tobacco use should be re- corded,
literature in this area and then rec- complete the causal pathway to foot since cigarette smoking is a risk factor
ommend what should be included in the ulceration (1,3–5). A list of the prin- not only for vascular disease but also
comprehensive foot exam for adult pa- cipal contributory factors that might re- for neuropathy.
tients with diabetes. The committee was sult in foot ulcer development is
cochaired by the immediate past and cur- provided in Table 1.
rent chairs of the ADA Foot Care Interest The most common triad of causes General inspection
Group (A.J.M.B. and D.G.A.), with other that interact and ultimately result in ul- A careful inspection of the feet in a well-
panel members representing primary ceration has been identified as neuropa- lit room should always be carried out
care, orthopedic and vascular surgery, thy, deformity, and trauma (5). As after the patient has removed shoes and
physical therapy, podiatric medicine and identification of those patients at risk of socks. Because inappropriate footwear
and foot
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● properly cited, the use is educational and not
From the 1Manchester Diabetes Centre, Manchester, U.K.; the 2Division of Endocrinology, Diabetes & for profit, and the work is not altered. See
Metabolism, University of Miami School of Medicine, Miami, Florida; the 3Dr. William M. Scholl http://creativecommons. org/licenses/by-nc-
College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North nd/3.0/ for details.
Chicago, Illinois; the 4Denver Department of Veterans Affairs Medical Center, Denver, Colorado; the
5
Carl T. Hayden VA Medical Center, Phoenix, Arizona; the 6American Association of Clinical
Endocrinologists, Jacksonville, Florida; the 7Department of Medicine, University of Missouri–Kansas
City School of Medicine, Kansas City, Missouri; the 8American Diabetes Association, Alexandria,
Virginia; the 9Department of Surgery, Texas A&M Health Science Center, Temple, Texas; the
10
Department of Family & Community Medicine, University of Missouri–Columbia School of Medicine,
Columbia, Missouri; the 11Department of Surgery, University of Arizona Health Sciences Center,
Tucson, Arizona; the 12Program in Physical Therapy and Department of Radiology, Washington
University School of Medicine, St. Louis, Missouri; the 13Depart- ment of Medicine, Mount Sinai
School of Medicine, New York, New York; and the 14Department of Orthopedic Surgery, University
of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Corresponding author: Andrew J.M. Boulton, aboulton@med.miami.edu.
This report was peer reviewed and approved by the Professional Practice Committee of the American
Diabetes Association, the Endocrine Practice Editorial Board, and the Board of Directors of the
American Association of Clinical Endocrinologists.
DOI: 10.2337/dc08-9021
© 2008 by the American Diabetes Association. Readers may use this article as long as the work is
DIABETES CARE, VOLUME 31, NUMBER 8, AUGUST 2008 143
deformities are common contributory factors in the development of foot ulcer-
ation (1,5), the shoes should be inspected and the question “Are these shoes appro-
priate for these feet?” should be asked.

Table 1—Risk factors for foot ulcers

• Previous amputation
• Past foot ulcer history
• Peripheral neuropathy
• Foot deformity
• Peripheral vascular disease
• Visual impairment
• Diabetic nephropathy (especially patients on dialysis)
• Poor glycemic control
• Cigarette smoking

144 DIABETES CARE, VOLUME 31, NUMBER 8, AUGUST 2008

Boulton and
Associates
Comprehensive foot examination and risk
assessment
Table o claudic a s et l Dermatolog
2— r ation Table 3— l c w a ical
Esse s • rest Key u e r assessment.
ntial h pain l e
components i The der-
featu a • o n a
of the n matological
res of nonhea s m s
r diabetic f assessment
histor ling k et s
p foot exam e should
y ulcer e at e
c l initially
Other I ar s
Past s t e include a
diabetes n s s
history e s i t global
complica al m
• n tions p o a e inspection,
ulcerat n l s) including in-
s • e n
ion • • N terdigitally,
a renal c t
• ulce def e for the
t (dialys t • foot
amput ratio u
i is, i or pulses presence of
ation n r
o transpl o mit • ABI, ulceration or
• • o
n ant) n y, l if areas of
Charc Dermato c e.g. abnormal
s • o indicated
ot joint a
, retinal logic , g erythema.
• l
e (visual • cla i The pres-
vascul ski l
t impairme w c ence of
ar u
c nt) n toe a callus
surger
. stat s s, l (particularly
y
) us: e pro with hemor-
•
• col s mi rhage), nail
angiop a
n Examples or, / ne s dystrophy,
lasty
e of thic b nt s or
•
g kne l me e paronychia
cigaret inappropria
te a ss, i tata s should be
te shoes
smoki ti dry s rsal s recorded (9),
include t
ng v nes hea m with any of
those that e e
Neuropat e s, ds, these
are cra r n
hic ( Ch findings
symptom excessively cki i t
e. arc prompting
s worn or are ng n 10-g
g ot referral to a
• too small • g join monofila specialist or
.,
p n
for the sweati : t ment 1
specialty
os person’s ng h of the
u (Fi clinic. Focal
iti feet (too • e following
m g.
4 or global
ve b narrow, too in m 1) skin
fe o •
(e n short, toe • temperature
ct r vibrati
.g e box too m differences
on
., s low), io r u between one
using
b s, resulting in n: h s foot and the
128-
ur f rub- bing, c a c Hz other may
ni e erythema, h g l tuning be predictive
n e e e e fork of either
blister, or
g t c w • vascular
callus.
or f k i a pinpri disease or
Features
sh e b n s ck ulceration
that should et
o e t ti sensati and could
ot be assessed w on
l o n also prompt
in during foot e •
d g referral for
g in- e ( ankle
e c specialty foot
pa spection n g reflexe
a a care (10 –
in are to u s
d l 13).
, ) outlined in es tt •
Musculoske
Table 3 fo l VPT
el Vascula e letal
u V
ec r and are r ri assessment.
fu s a
tri sympto discussed n The mus-
n ? s
ca ms below. g culoskeletal
g M c
l • b assessment
u u
 Boulton and
should in the pathway to clinicians to Monofila ments are Associates
ent to asked
screenin
include neuropathi diabetic identify g exam ments, con- use, as whether
evaluation c foot and foot LOPS, — sometimes structed to many the
for any most often ulceration although normall known as buckle commer- monofilam
gross affects the (1,4,5,7). ideally two y the Semmes- when a 10- cially ent is being
deformity midfoot. The clinical of these 10-g Weinstein g force is available applied to
(14). Rigid This may exam should be monofila monofilam applied; monofila the
deformities present as recommende regularly ment and ents, were loss of the ments particular
are defined a unilateral d, however, performed one other originally ability to have been site; the
as any con- red, hot, is designed during the test. One used to detect this shown to patient
tractures swollen, to identify or more diagnose pressure at be should
that cannot flat foot loss of abnorma sensory one or inaccurat recog- nize
easily be with protective l tests loss in more e. Single- the
manually profound sen- sation would leprosy anatomic use dis- perception
reduced and defor- mity (LOPS) suggest (21). sites on the posable of pressure
are most (18 –20). rather than LOPS, Many plantar monofila as well as
frequently A patient early while at prospectiv surface of ments or identify
found in the with neuropa- least two e studies the foot those the correct
digits. suspected thy. The normal have has been shown to site. Areas
Common Charcot diagnosis tests (and confirmed associated be of callus
forefoot arthropathy and no that loss with loss accurate should
deformities should be management abnormal of pressure of large- by the always be
that are immedi- of the latter test) sensation fiber nerve Booth avoided
known to ately were would using the function. and when
increase referred to covered in a rule out 10-g It is Young testing for
plantar pres- a specialist 2004 ADA LOPS. monofilam recommen (23) pressure
sures and for further technical The last ent is ded that study are perception.
are assessment review (7). test highly four sites recomme 128-Hz
associated and care. The clinical listed, predictive (1st, 3rd, nded. The tuning
with skin exami- vibration of and 5th sensation forks. The
break- down nation to assessme subsequent metatarsal of tuning fork
include N identify nt using ulceration heads and pressure is widely
metatarsal e LOPS is a (3,21,22). plantar using the used in
phalangeal u simple and biothesio Screen- surface of buckling clinical
joint r re- quires no meter or ing for distal 10-g practice
hyperextensi o expensive similar sensory hallux) be mono- and pro-
on with l equipment. instru- loss with tested on filament vides an
interphalang o Five ment, is the 10-g each foot. should easy and
eal flex- ion g simple widely mono- The first be inexpensiv
(claw toe) or i clinical tests used in filament is technique demonstr e test of vi-
distal (Table 3), the U.S.; in for testing ated to bratory
c
phalangeal each with however, widesprea pressure the sensation.
a
exten- sion evidence identifica d use perception patient on Vibratory
(hammer l from well- across the with the a sensation
tion of
toe) (15– conducted the world, and 10-g proximal
17). a prospective patient its efficacy monofilam site (e.g.,
(Examples s clinical with in this ent is upper
of these s cohort LOPS regard has illustrated arm). The
deformities e studies, are can been in Fig. 2; sites of
are shown in s considered easily be confirmed patients the foot
Fig. 1.) s useful in carried in a should may then
An m the out number of close their be
important e diagnosis of without trials, in- eyes while examined
and often n LOPS in the this or cluding being by
overlooked t diabetic foot other the recent tested. asking
or Peripheral (1–7). The expensiv Seattle Caution is the
misdiagnose neuropathy task force e Diabetic necessary patient
d condition is the most agrees that equipme Foot Study when to re-
is Charcot com- mon any of the nt. (4,21,23,2 selecting spond
ar- component five tests 10-g 4). the brand “yes” or
thropathy. cause in listed could monofil Nylon of “no”
This occurs the be used by aments. monofila monofilam when
Comprehensive foot examination and risk
assessment

Figure 1—Foot deformities. These sites are frequent locations for diabetic foot ulceration. A: Claw toe deformity. Note the buckling phenomenon
that causes increased pressure on the dorsal hammer digit deformity, as well as on the plantar metatarsal head. B: Bunion and overlapping toes.
This deformity can lead to pressure ulceration between the digits, on the dorsal or plantar surfaces of displaced digits, and over the medial
first metatarsophalangeal joint. C: A rocker-bottom deformity secondary to Charcot arthropathy can cause excessive pressure at the plantar
midfoot, increasing risk for ulceration at that site.
 Boulton and
Associates
should be form the pull, with
tested over skin. the ankle
the tip of Inability to reflexes
the great perceive then
toe pin- prick retested
bilaterally. over with
An either reinforcem
abnormal hallux ent. Total
response would be absence of
can be regarded as an- kle
defined as an reflex
when the abnormal either at
patient test result. rest or
loses vi- Ankle upon
bratory reflexes. reinforce-
sensation Absence ment is
and the of ankle regarded as
examiner re- flexes an
still has also abnormal
perceives it been result.
while associated Vibration
holding the with in- perception
fork on the creased threshold
tip of the risk of foot testing.
toe (3,4). ulceration The
Pinprick (4). Ankle biothesiom
sensation. reflexes can eter (or
Similarly, be tested neurothesi
the in- with the om- eter)
ability of a patient ei- is a simple
subject to ther handheld
perceive kneeling or device that
pinprick resting on gives
sensation a semiquantit
has been couch/table ative
associated . The assessment
with an in- Achilles of vi-
creased tendon bration
risk of should be perception
ulceration stretched threshold
(4). A until the (VPT). As
dispos- ankle is in for
able pin a neutral vibration
should be position using the
applied be- fore 128-Hz
just striking it tuning
proximal to with the fork,
the toenail tendon vibration
on the hammer. If perception
dorsal a response using the
surface of is initially biothesiom
the hallux, absent, the eter is also
with just patient can tested over
enough be asked to the pulp of
pressure to hook the hallux.
de- fingers With the
together patient
and lying su-
Comprehensive foot examination and risk
assessment

Figure 2—Upper panel: For performance of the 10-g monofilament test, the device is placed perpendicular to the skin, with pressure applied
until the monofilament buckles. It should be held in place for 1 s and then released. Lower panel: The monofilament test should be performed
at the highlighted sites while the patient’s eyes are closed.
 Boulton and
pedis or therefore Associates
pine, the s extremity ankle
stylus of s risk status. posterior systolic be part of
the e Vascular tibial pressure the annual
instrument s examina- arteries) is by the comprehen
is placed s tion should measured higher of sive foot
over the m include using a the two exam in
dorsal e palpation standard brachial these
hallux and n of the Doppler systolic patient
the t posterior ultrasonic pressures subgroups
amplitude Peripheral tibial and probe. This (8). An . ABI
is arterial dorsalis technique is ABI measurem
increased disease outlined in 0.9 is ents may
pedis pulses
until the (PAD) is a Fig. normal, be
(10,26),
patient can com- 3. The ABI 0.8 is misleading
which
detect the ponent is obtained associate in diabetes
should be
vibration; cause in by dividing d with because
the characterize
approxim d as either the claudicat the
resulting ately one- presence
“present” or ion, and
number is third of of medial
“absent” 0.4 is
known as foot calcinosis
(26). commonl
the VPT. ulcers renders
Diabetic y
This and is the
process patients with associate
often a signs or d with arteries
should significan symp- toms ischemic incompres
initially be t risk of vascular rest pain sible and
demonstrat factor disease and results in
ed on a associate
proximal (Table 2) or tissue falsely
d with necrosis. elevated
site, and ab- sent
recurrent The or supra-
then the pulses on
wounds ADA systolic
mean of screening
(5,25). Consens ankle
three foot
Therefore us Panel
readings is , the examination
taken over should on PAD
assessme
each undergo recomme
nt of PAD
hallux. A ankle nded
is
VPT 25 V brachial measure
important
is pressure ment of
in
regarded defining index (ABI) ABI in di-
as overall pressure abetic
abnormal lower- testing and patients
and has be con- over 50
been sidered for a years of
shown to possible age and
be strongly referral to a consider
predictive vascular ation of
of subse- specialist. ABI
quent foot The ABI is a measure
ulceration simple and ment in
(15,22). younger
easily
reproducible patients
V method of with
a diagnosing multiple
s vas- cular PAD risk
c insufficienc factors,
u y in the repeating
l lower normal
a limbs. Blood tests
r pressure at every 5
the ankle years (8).
(dorsalis ABI may
a
Comprehensive foot examination and risk
assessment

Figure 3—Lower-extremity circulation and the ABI test. A: Anterior view, right lower limb, normal arterial anatomy. B: ABI. Place blood
pressure cuff above pulse. Place Doppler probe over arterial pulse; a: posterior tibial artery, b: dorsalis pedis artery. ABI calculation: Divide
ankle systolic blood pressure by brachial artery systolic blood pressure. (ABI 0.9 is normal.) Adapted from Khan et al., JAMA 295:536 –546,
2006.
 Boulton and
Associates
pressures. referral sociated CONCL present,
In the and with an USIONS more fre-
presence of subseque increased — It quent
incompress nt cannot be evaluatio
risk for
- ible calf therapy over- n of the
or ankle ulceration,
by the stated that diabetic
arteries hospitalizati
specialty the foot is
(ABI on, and complicati recomme
clinician
1.3), amputa- tion ons of the nded
or team
measureme (17). dia- betic dependin
(17,20)
nts of Patients in foot are g on risk
digital and
risk category common, cate-
arterial frequency
of follow- 0 gen- erally complex, gory, as
systolic do not need and costly, describe
pressure up by the
gener- referral and mandating d above
(toe aggressive and in
alist or should
pressure) and proac- Table 4.
or specialist. receive
Increased general foot tive
transcutane
care preventati
ous oxygen category
education ve
tension is as-
and undergo assessment
may be
performed. s by
comprehensi
general-
ve foot
Risk ists and
examina- specialists
clas tion
sific . All
annually. patients
atio Patients in with
n foot risk diabetes
and cate- gory 1 must have
refer
may be their feet
ral/
managed by evaluated
f
a generalist at least at
o
or specialist yearly
l
l every 3– 6 intervals
o months. for the
w Consider- presence
- ation should of the
u predisposi
be given to
p ng factors
an initial
Once the for
special- ist ulceration
patient has referral to
been and
assess the amputatio
thoroughly need for
as- sessed n
specialized (neuropat
as
treatment hy,
described
and follow- vascular
above, he
up. Those in disease,
or she
categories 2 and
should be
and 3 should deformitie
assigned to
be re- ferred s). This
a foot risk
to a foot care report
category summarize
(Table 4). specialist or
specialty s a simple
These protocol
categories clinic and
for doing
are seen every
so. If
designed to 1–3 months. abnormalit
direct ies are
Comprehensive foot examination and risk
assessment
Table 4—Risk classification based on the comprehensive foot examination

Risk category Definition Treatment recommendations Suggested follow-up

0 No LOPS, no PAD, no deformity • Patient education including advice Annually (by generalist and/or specialist)
on appropriate footwear.
1 LOPS deformity • Consider prescriptive or Every 3–6 months (by generalist or
accommodative footwear. specialist)

2 PAD LOPS
3 History of ulcer or amputation
It is through systematic examination
and risk assessment, patient education,
and timely referral that we may further
reduce the unnecessarily high preva-
lence of lower-extremity morbidity in this
population.
Acknowledgments — The meeting of the
Task Force was supported by an unrestricted
educational grant from KCI, San Antonio, TX.
A.J.M.B. has received honoraria/consulting
fees from Pfizer and Eli Lilly. R.G.F. has served
on the speakers’ bureaus of KCI, Oculus,
Pfizer, and Organogenesis and has received re-
search support from Regenesis Biomedical
and Derma Sciences. L.A.L. is a stockholder
and on the board of directors of Diabetica
Solutions and Pathways Disease
Management; a stock- holder of XL Health;
on the scientific advisory board and
speakers’ bureau of and has re- ceived
research support from KCI; and a
stockholder and on the scientific advisory
boards of Cytomedics and Pegasus. P.S. is on
the scientific advisory boards of Advanced
Biohealing and Greystone; a consultant for
Calretex, Cardiun, Heal Or, Taisho, and Hy-
permed; a speaker for Fox Hollow, Bristol-
Meyers Squibb, sanofi-aventis, Merck, and
Organogenesis; and has received research
grants from Tissue Repair Company, Baxter,
and PamLab. D.K.W. has received honoraria
from Small Bones Innovation, Diabetic Global
Foot Conference, and New Horizons in
Cardio-
vascular Medicine.
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