As the diabetic population grows, so does the need for a more streamlined diabetic foot screening program. This will allow for timely referral of appropriate patients for more specialized care prior to hospitalization or prophylactic amputation. Primary care providers are the front-line guardians against diabetic complications, including the diabetic foot. However, the shortage of primary care providers is disproportionate to the growth of the diabetic population, greatly increasing the burden of health education, disease screening and timely referrals.
The “3-Minute Foot Exam” is an easy-to-use method for assessing the lower extremities of diabetic patients. It consists of three parts, each of which is completed in less than one minute: history, physical examination, and patient education.
1. History
A complete medical history can help the provider identify certain risk factors that may increase the patient’s risk of developing lower extremity complications. Asking patients with diabetes about their glycemic control and history of lower extremity disease (e.g., trauma or amputation) is key to screening for diabetic foot.
Patients with previous lower extremity ulcers or amputations have a 60% increased risk of reulceration. It is equally important to ask patients about their previous vascular status and smoking history, as these are associated with peripheral arterial disease.
2. Physical examination
A careful foot examination should be performed in every patient with suspected or confirmed diabetes. The examination includes an assessment of the skeletal muscle system, the nervous system, the vascular status of the lower extremities, and an assessment of the skin condition of the patient’s lower extremities. Up to 50% of patients may be asymptomatic due to loss of sensory protection (LOPS). Failure to identify any early problems may result in adverse outcomes, including hospitalization and amputation.
The basic examination of the diabetic foot includes examination of the skeletal/muscular system, the nervous system, the vasculature, and the skin. Examining all of these systems may sound cumbersome, but with continued practice, providers can complete a diabetic foot exam quickly and thoroughly.
①Skeletal muscle system examination
This part should focus on any biomechanical abnormalities of the foot and ankle including deformities such as bunions, mallet toes and bony protrusions. Restricted range of motion in any joint of the foot and ankle can significantly increase the risk of ulceration. Muscle strength should also be assessed, including examination of weaknesses and asymmetries.
②Neurological examination
LOPS is associated with 75% of non-traumatic diabetic foot amputations and can lead to decreased skin integrity and musculoskeletal imbalance and increased ulcer risk.
A variety of devices are available to detect LOPS, including vibro-sensory threshold devices, Semmes-Weinstein monofilament testing, and 128-Hz tuning forks. However, these devices may not be available in primary care units.
The Ipswich Touch Test (IPTT) is another neurological test that is performed by having the patient’s eyes closed while the examiner gently places the index finger on the patient’s first, third, and fifth toes for 2 seconds. The patient answers “yes” when he or she feels the tester’s finger. This method has been found to have the same sensitivity and specificity as the Semmes-Weinstein monofilament test and does not require any special equipment.
(iii) Vascular examination
This part of the examination includes palpation of the femoral, N, and posterior tibial muscles bilaterally and assessment of the dorsalis pedis artery pulsation. A diminished or absent pulse can be an indicator of the severity of vascular damage.
A large body of data suggests that inadequate circulation can affect impaired healing in up to half of patients with diabetic foot ulcers. Skin temperature, hair growth, capillary refill time, and bilateral lower extremity edema should likewise be evaluated and compared. Abnormal findings may also indicate the presence of peripheral arterial disease.
④ Dermatologic examination
Dermatologic examination includes a thorough examination of skin abnormalities including dryness, cracking, discoloration, and the formation of hard skin nodules, which may be precursors to ulceration. Abnormal manifestations suggest prompt referral for evaluation and treatment by more specialized personnel.
Primary care providers should also examine lower extremity toes for thickened, elongated or ingrown nails and skin maceration or tears between the toes, which can be easily overlooked and can lead to adverse outcomes.
3. Patient education
Patient education is especially important when it comes to helping at-risk patients understand their disease status and usual care. Studies have found that a lack of proper diabetes education can increase the risk of ulcer recurrence by 90%. Patient education addresses foot hygiene, skin and toe care, and proper footwear can reduce ulcer-causing injuries.
Patient education can improve patient understanding of the associated complications and minimize the risk of diabetic foot ulcers and short-term amputation. More research data are needed to determine the long-term benefits of the type of education that would be most beneficial to patients.
When the 3-minute foot examination is complete, primary care providers should have a full understanding of the patient’s condition and the next steps in treatment triage. These exams can also be used to guide patients on whether they need to be referred.