Expansion
Skin, deformity, neuropathy and circulation
Expansion
Look, including between the toes and on the soles and heels
- Skin: dryness, fissures, callus, ulcers, maceration, fungal infection
- Nails: thickening, ingrowing, poor self-care
- Deformity: clawing of the toes, prominent metatarsal heads, hallux valgus, Charcot rocker bottom foot, amputations
- Colour, hair loss, previous ulcer scars
- Footwear: fit, wear pattern, foreign objects inside
Feel
- Temperature, comparing feet; a difference of more than 2 degrees suggests Charcot or infection
- Pulses: dorsalis pedis and posterior tibial, plus capillary refill and the ankle brachial pressure index where indicated
Neuropathy
- 10 g monofilament at 10 sites, or fewer per local protocol, with the patient’s eyes closed. Inability to feel it at any site indicates loss of protective sensation
- 128 Hz tuning fork at the hallux, pinprick, and ankle reflexes
Risk stratification
| Risk | Findings |
|---|---|
| Low | No risk factors other than callus |
| Moderate | Deformity, or neuropathy, or non-critical ischaemia |
| High | Previous ulcer or amputation, dialysis, or two or more of the above |
| Active | Ulcer, infection, Charcot, gangrene, critical ischaemia |
An active problem needs referral to the multidisciplinary foot service within 24 hours.
The neuropathic ulcer sits on a plantar pressure point, is painless, punched out and surrounded by callus, and the foot is warm with palpable pulses; the ischaemic ulcer sits on the margins and toes, is painful, and the foot is cold and pulseless.