Comprehensive Foot Exam

Comprehensive Foot Exam

Also called: Foot Exam


A comprehensive foot exam is one of the easiest, most useful and least invasive tools available to people with diabetes. This test can catch foot problems early and reduce the risk of infection, ulcer, deformities and amputation.

A variety of comprehensive foot exams are available. They typically include assessment of:

  • Sensation and diabetic neuropathy
  • Circulation and peripheral arterial disease
  • Injury and deformity
  • Range of motion and strength
  • Medical history and current symptoms
  • Footwear needs
  • Need for patient education

People with diabetes should have a comprehensive foot exam at least once a year. The test should be performed more frequently if any risk factors are present, such as impaired sensation or history of foot ulcer.

About comprehensive foot exam

A comprehensive foot exam is a series of assessments that can help diabetic patients avoid complications. Types of foot complications include:

  • Infection by bacteria, fungi, viruses or parasites, often through a skin crack or minor wound
  • Bunions, corns and calluses
  • Ulcer, an open sore that is harder to heal with diabetes
  • Bone infection (osteomyelitis)
  • Gangrene, the death of tissues
  • Foot or leg amputation that can result from gangrene

The National Institutes of Health (NIH) and other U.S. government agencies urge people with diabetes to get a comprehensive foot exam at least once a year. This would decrease the number of foot and leg amputations, one of the most devastating yet preventable consequences of diabetes.

People with diabetes account for about 7 percent of the U.S. population but more than 60 percent of nontraumatic lower limb amputations, according to the federal Centers for Disease Control and Prevention (CDC). Most of these amputations stem from minor injuries that a foot examination could have prevented or brought under control in time.

In addition to undergoing comprehensive foot exams, people with diabetes can help protect themselves by:

  • Performing a monthly self-check of foot sensation.
  • Following easy guidelines to clean and inspect the feet daily.

Comprehensive foot exams usually categorize patients with diabetes according to risk level. This classification helps high-risk individuals receive extra medical attention, instruction and referrals to specialists. High-risk patients with diabetes should have a comprehensive foot exam more often than once a year, at every medical appointment if possible.

A patient is considered at high risk if one or more of the following complications exist:

  • Lack of pulse in the foot
  • Severe foot deformity, such as Charcot foot
  • Loss of protective sensation, the ability to feel minor injuries
  • Previous foot ulcer
  • Previous amputation

Before the comprehensive foot exam

A comprehensive foot exam does not require the patient to prepare, other than making the appointment, unless a diagnostic test is used that requires fasting. However, everyone with diabetes should perform a self-test foot screen every month, according to the U.S. Department of Health and Human Services (HHS). This quick, easy and painless check of sensation indicates whether an individual needs further evaluation.

The self-test foot screen uses one simple tool, a filament that can be obtained free of charge from HHS.

The filament is touched against five locations on the bottom of each foot: the big toe, the fourth toe, and the right, center and left parts of the fleshy ball of the foot. People who have difficulty reaching, poor vision or other physical problems should ask a relative, friend or caregiver to do it.

Instructions for the self-test foot screen include:

  • Hold the filament by its handle.
  • Touch the filament against the skin on each of the 10 sites for a second or two.
  • If a site has a sore, scar or callus, apply the filament next to it, not on it.
  • On the foot illustration, mark the sites where the filament can and cannot be felt.
  • Wipe the filament with alcohol so it can be reused the next month.

Inability to feel the filament at any of the 10 sites indicates impaired sensation and risk of foot problems. A physician or other health professional should be consulted for a comprehensive foot exam.

Other methods that may help detect foot conditions early include daily use of an infrared skin thermometer.

During and after the comprehensive foot exam

A comprehensive foot exam is an outpatient procedure usually performed by a physician in an office or clinic. More basic exams may be performed by a physical therapist, nurse, physician assistant or other health professional.

A comprehensive foot exam has many variations. Typically a patient can expect most or all of the following features, which are painless and noninvasive unless indicated otherwise:

  • Medical history. The physician will review and ask about:
    • Prior conditions and diabetic risk factors, such as ulcer, neuropathy (nerve damage), peripheral arterial disease or other types of diabetic angiopathy, hyperglycemia (high glucose) or high blood pressure.
  • Current symptoms, such as pain when walking (claudication), numbness and any changes in the foot since the last evaluation.
  • Physical examination. The physician will visually inspect and palpate (feel) the feet to note any deformities, abrasions, swelling, redness, abnormally warm or cool areas, etc. The physician will note whether pedal pulses in both feet are intact, impaired or absent.
  • Sensory and neurological assessment. It is important to note and document any loss of protective sensation, which increases the risk of foot injuries. Tests of sensation include:
    • Monofilament test. A standardized instrument consisting of a nylon fiber mounted on a holder. The physician touches the filament against several sites on the patient’s soles with just enough pressure to bend. This fast, painless and frequently used evaluation of sensation can diagnose peripheral neuropathy. Nerve damage is apparent if the individual cannot feel the filament.
    • Additional tests such as nerve conduction studies, electromyography and quantitative sensory testing.
  • Circulatory assessment. The physician may go beyond palpation of pulses in the feet to perform one or more further tests of blood flow, such as:
    • Ankle brachial index (ABI). A painless, easy, noninvasive way to diagnose peripheral arterial disease by comparing blood pressure of the ankles to the arms. A blood pressure cuff is used on each arm and each ankle to obtain the systolic pressure. A handheld Doppler ultrasound device, which emits harmless sound waves, may be used to help get the readings. ABI is an ankle’s systolic blood pressure divided by the highest systolic reading of either arm. An abnormal result is usually considered to be a ratio of less than 0.9 to 1.0. An ABI of less than 0.5 indicates severe blockage of the arteries serving the leg. Sometimes the test is repeated after the patient walks for several minutes on a treadmill. A decrease in ABI after exercise is a further indication of impaired circulation.
    • Toe brachial index (TBI). Similar to the ABI, but including blood pressure of a toe instead of ankle. TBI might be used in place of ABI with longtime diabetes patients, elderly people or people with kidney disease, whose ankle arteries can be too rigid to give accurate blood pressure readings. An abnormal result is usually considered to be a ratio of less than 0.8.
    • Doppler ultrasound. Use of a device emitting harmless, painless sound waves to measure blood flow through the arteries.
    • Angiography (also called arteriography). A dye called a contrast medium is injected into a blood vessel. X-rays can then be used to spot blockage or narrowing of blood vessels. Fasting may be required beforehand for this test.
    • Magnetic resonance angiography (MRA). A painless procedure in which a machine produces a magnetic field to create two- and three-dimensional images of tissue. MRA is a type of magnetic resonance imaging (MRI) that studies the structure of blood vessels. It is a noninvasive alternative to angiography.
    • CAT scan (computed axial tomography). A test that uses a rotating x-ray tube to take pictures from all 360 degrees. A computer compiles the pictures to produce cross-sectional images of the body. The test takes up to an hour. The patient may be instructed to fast for several hours beforehand if a contrast medium is injected. The patient lies down on the x-ray table and is asked to hold still in various positions.
  • Footwear assessment. The physician will note whether the patient’s shoes and socks are appropriate, such as whether they fit correctly to reduce the risk of blisters. Therapeutic shoes or inserts especially designed for people with diabetes may be prescribed.
  • Treatment plan. The plan of care includes any needed medications and other interventions. Often it will involve:
    • Patient education in matters such as daily foot inspection, daily foot care and hygiene, footwear, exercise and diet. The patient should be able to demonstrate foot inspection and other instructed techniques. Otherwise, family members or other caregivers will need to be involved.
    • Referrals as needed for further evaluations, foot specialists such as podiatrists, diabetic footwear, home health agencies, etc.

After the comprehensive foot exam, patients can resume normal activities unless the physician finds problems that require additional testing, hospitalization, bed rest or other interventions.

Scientists are refining technologies that can find early signs of diabetic foot problems and that may one day become part of a comprehensive foot exam. Medical hyperspectral imaging (MHSI) and magnetic spectroscopy are able to detect diabetic skin changes (reduced oxygen and diminished muscle energy reserves) before ulcers develop. Development of these tools could identify at-risk individuals and help prevent ulcers and amputations.

Benefits and risks of comprehensive foot exam

A foot exam has few risks. Most of the assessments involved are noninvasive and unlikely to result in injury, unless a patient is already severely ill or frail. For example, there is a small chance that a blood pressure reading could tear the skin on the arm or ankle of an elderly diabetes patient who has thin skin.

Radiological tests that might be part of a comprehensive foot exam involve minor risks. CAT scan and angiography are x-ray studies that expose the patient to small amounts of radiation that are generally considered safe. Some people may be allergic to the dye used as a contrast medium.

The great benefit of a comprehensive foot exam is its ability to reduce incidence of ulcers and amputations. Only 48 percent of diabetic American adults are receiving three tests that are effective in preventing diabetic complications – foot exams, eye exams and glucose tests – the Department of Health and Human Services reported in 2007. The National Institutes of Health (NIH) urges people with diabetes to have their feet examined at least once a year and control their disease as the most effective means of preventing amputations.

Alternatives and variations of foot exam

There are several types of comprehensive foot exams, many with similar features. The type of foot exam chosen will require a specific professional to perform the exam. A physician may follow the procedures outlined in one of these exams, or select and combine parts of one or more of them. Popular versions include:

  • Lower Extremity Amputation Prevention (LEAP) exams. The federal Bureau of Primary Health Care has developed these exams. The bureau also recommends the self–test foot screen described in the section Before the comprehensive foot exam. LEAP focuses on diagnosing loss of protective sensation, where an individual can no longer feel blisters, cuts and other seemingly minor problems that can become serious conditions for people with diabetes. The patient is rated in one of four risk categories depending on severity of any loss of protective sensation. There are two types of LEAP tests:
    • Level One LEAP Foot Screen. A test using filament to check sensation and manual examination to check physical features, carried out by a nurse or other health professional with knowledge of the foot. The test includes 13 areas of concern for each foot. It notes factors such as sensation, pulse, deformity, ulcer, swelling, skin temperature, muscle weakness, ankle mobility, calluses, toenail problems and footwear.
    • Level Three LEAP Foot Screen. A more thorough examination carried out by a physician or physical therapist trained in foot biomechanics. Level three includes the patient’s history, manual examination of strength and range of motion for every foot and toe joint, filament testing of sensation at 10 sites on each foot, four vascular tests for pulses and circulation on each foot, examination for any deformities, vision test and evaluation of footwear. (Note: LEAP does not have a level two screening.)
  • The National Diabetes Education Program’s “Feet Can Last a Lifetime” foot screening. This program considers eight areas:
    • Medical history, including risk factors such as neuropathy
      Diabetic Neuropathy
    • Current condition, including symptoms such as pain
    • Foot exam, focusing on nails, deformities, foot pulses and skin condition
    • Sensory foot exam, using the nylon filament test on each foot
    • Risk categorization, low or high, depending on the above factors
    • Footwear assessment, noting any need for therapeutic shoes or inserts
    • Education, noting whether patient has been instructed in and can perform self–care
    • Management plan, including any need for instruction or specialist referrals

A physician can offer more information on the types, procedures, benefits and risks of a comprehensive foot exam.

Questions for your doctor regarding foot exam

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about comprehensive foot exam:

  1. Do I have increased risk of foot problems?
  2. How often should I have a comprehensive foot exam, and by whom?
  3. What should it include?
  4. How will my sensation and nerves be assessed?
  5. How will my circulation and blood vessels be assessed?
  6. What does my comprehensive foot exam indicate?
  7. Do I need any additional tests?
  8. If treatment is needed, what are my options, and which do you recommend?
  9. What sort of self–exam should I do on my feet, and how often?
  10. Are there other ways I can reduce my risk of foot problems?
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