Assessment of a Foot with Diabetic Foot Ulcer
Classification and Assessment
- The American Diabetes Association recommends determining whether the ulcer is neuropathic, neuro-ischemic, or purely ischemic through history and clinical examination 1, 2
- The International Working Group on the Diabetic Foot suggests palpating dorsalis pedis and posterior tibial pulses in all patients 1, 2
- Measuring ankle-brachial index (ABI) using Doppler ultrasound can help exclude peripheral arterial disease (PAD) if ABI is 0.9–1.3 with triphasic pedal pulse waveform 1, 2
- The American College of Cardiology recommends measuring toe-brachial index (TBI) when ABI is unreliable; TBI ≥0.75 excludes PAD 1, 2
- Toe systolic blood pressure <30 mmHg suggests PAD and inability to heal—refer immediately for vascular evaluation 3
Neurological Assessment
- The American Diabetes Association recommends testing for loss of protective sensation (LOPS) using 10-g monofilament at multiple plantar sites 3
- Performing at least one additional neurological test: pinprick, temperature perception, ankle reflexes, or vibratory perception with 128-Hz tuning fork can help confirm LOPS 3
Infection Assessment
- The Infectious Diseases Society of America (IDSA) and the International Working Group on the Diabetic Foot (IWGDF) recommend diagnosing infection by the presence of at least two signs or symptoms of inflammation: redness, warmth, induration, pain/tenderness, OR purulent secretions 1, 2
- The IDSA/IWGDF system classifies infection severity into four grades: Grade 1 (Uninfected), Grade 2 (Mild), Grade 3 (Moderate), and Grade 4 (Severe) 4, 5
Osteomyelitis Assessment
- The American Diabetes Association recommends assessing for osteomyelitis in patients with longstanding wounds, deep wounds, wounds overlying bone, or positive probe-to-bone test 1, 2
- Obtaining plain radiographs for screening can help diagnose osteomyelitis in most cases 1, 2