Abstract
Foot ulceration is one of the most common precursors to lower extremity amputations among persons with diabetes (1,2). Ulcerations are pivotal events in limb loss for two important reasons. They allow an avenue for infection (3), and they can cause progressive tissue necrosis and poor wound healing in the presence of critical ischemia. Infections involving the foot rarely develop in the absence of a wound in adults with diabetes, and ulcers are the most common type of wound in this population (3). Foot ulcers therefore play a central role in the causal pathway to lower extremity amputation (4).
Preview
Unable to display preview. Download preview PDF.
References
Boulton AJM, Vileikyte L. Pathogenesis of diabetic foot ulceration and measurements of neuropathy. Wounds 2000;12(Suppl B):12B–18B.
Reiber GE, Smith DG, Carter J, et al. A comparison of diabetic foot ulcer patients managed in VHA and non-VHA settings. J Rehabil Res Dev May–Jun 2001;38(3):309–317.
Armstrong DG, Lipsky BA. Advances in the treatment of diabetic foot infections. Diabetes Technol Ther 2004;6:167–177.
Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care 1990;13:513–521.
Armstrong DG, Peters EJ, Athanasiou KA, Lavery LA. Is there a critical level of plantar foot pressure to identify patients at risk for neuropathic foot ulceration? J Foot Ankle Surg 1998;37(4):303–307.
Cavanagh PR, Ulbrecht JS, Caputo GM. Biomechanical aspects of diabetic foot disease: aetiology, treatment, and prevention. Diabet Med 1996;13(Suppl 1):S17–S22.
Lavery LA, Vela SA, Lavery DC, Quebedeaux TL. Reducing dynamic foot pressures in high-risk diabetic subjects with foot ulcerations. A comparison of treatments. Diabetes Care 1996;19(8):818–821.
Lavery LA, Lavery DC, Quebedeax-Farnham TL. Increased foot pressures after great toe amputation in diabetes. Diabetes Care 1995;18(11):1460–1462.
Brand PW. The diabetic foot, in Diabetes Mellitus, Theory and Practice (Ellenberg M, Rifkin H, eds.) 3rd ed. Medical Examination Publishing, New York, 1983, pp. 803–828.
King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections [see comments]. Diabetes Care 1998;21(9):1414–1431.
Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in persons with diabetes. JAMA 2005;293(2):217–228.
Plank J, Haas W, Rakovac I, et al. Evaluation of the impact of chiropodist care in the secondary prevention of foot ulcerations in diabetic subjects. Diabetes Care 2003;26(6):1691–1695.
Ronnemaa T, Hamalainen H, Toikka T, Liukkonen I. Evaluation of the impact of podiatrist care in the primary prevention of foot problems in diabetic subjects. Diabetes Care 1997;20(12):1833–1837.
Lavery LA, Armstrong DG, Vela SA, Quebedeaux TL, Fleischli JG. Practical criteria for screening patients at high risk for diabetic foot ulceration. Arch Intern Med 1998;158:158–162.
Boyko EJ, Ahroni JH, Stensel V, Forsberg RC, Davignon DR, Smith DG. A prospective study of risk factors for diabetic foot ulcer. The Seattle Diabetic Foot Study. Diabetes Care 1999;22(7):1036–1042.
Abbott CA, Carrington AL, Ashe H, et al. The north-west diabetes foot care study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med 2002;19(5):377–384.
Peters EJ, Lavery LA. Effectiveness of the diabetic foot risk classification system of the International Working Group on the Diabetic Foot. Diabetes Care 2001;24(8):1442–1447.
Goldner MG. The fate of the second leg in the diabetic amputee. Diabetes 1960;9:100–103.
Armstrong DG, Lavery LA, Vela SA, Quebedeaux TL, Fleischli JG. Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration. Arch Int Med 1998;158:289–292.
Quebedeaux TL, Lavery LA, Lavery DC. The development of foot deformities and ulcers after great toe amputation in diabetes. Diabetes Care 1996;19(2):165–167.
Murdoch DP, Armstrong DG, Dacus JB, Laughlin TJ, Morgan CB, Lavery LA. The natural history of great toe amputations. J Foot Ankle Surg 1997;36(3):204–208.
Uccioli L, Faglia E, Monticone G, et al. Manufactured shoes in the prevention of diabetic foot ulcers. Diabetes Care 1995;18(10):1376–1378.
Helm PA, Walker SC, Pulliam GF. Recurrence of neuropathic ulcerations following healing in a total contact cast. Arch Phys Med Rehabil 1991;72(12):967–970.
Reiber GE, Vileikyte L, Boyko EJ, et al. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care 1999;22(1):157–162.
Olaleye D, Perkins BA, Bril V. Evaluation of three screening tests and a risk assessment model for diagnosing peripheral neuropathy in the diabetes clinic. Diabetes Res Clin Pract 2001;54(2):115–128.
Liniger C, Albeanu A, Bloise D, Assal JP. The tuning fork revisited. Diabet Med 1990;7(10):859–864.
Kastenbauer T, Sauseng S, Brath H, Abrahamian H, Irsigler K. The value of the Rydel-Seiffer tuning fork as a predictor of diabetic polyneuropathy compared with a neurothe-siometer. Diabet Med 2004;21(6):563–567.
Thivolet C, el Farkh J, Petiot A, Simonet C, Tourniaire J. Measuring vibration sensations with graduated tuning fork. Simple and reliable means to detect diabetic patients at risk of neuropathic foot ulceration. Diabetes Care 1990;13(10):1077–1080.
Armstrong DG. The 10-g monofilament: the diagnostic divining rod for the diabetic foot? (editorial) (in process citation). Diabetes Care 2000;23(7):887.
Sorman E, Edwall LL. (Examination of peripheral sensibility. Vibration test is more sensitive than monofilament test). Lakartidningen 2002;99(12):1339–1340.
Gin H, Rigalleau V, Baillet L, Rabemanantsoa C. Comparison between monofilament, tuning fork and vibration perception tests for screening patients at risk of foot complication. Diabetes Metab 2002;28(6 Pt 1):457–461.
Rith-Najarian SJ, Stolusky T, Gohdes DM. Identifying diabetic patients at risk for lower extremity amputation in aprimary health care setting. Diabetes Care 1992;15(10):1386–1389.
Pham HT, Armstrong DG, Harvey C, Harkless LB, Giurini JM, Veves A. Screening techniques to identify the at risk patients for developing diabetic foot ulcers in a prospective multicenter trial. Diabetes Care 2000;23:606–611.
Yong R, Karas TJ, Smith KD, Petrov O. The durability of the Semmes-Weinstein 5.07 monofilament. J Foot Ankle Surg 2000;39(1):34–38.
Booth J, Young MJ. Differences in the performance of commercially available 10-g monofilaments. Diabetes Care 2000;23(7):984–988.
Ulbrecht JS, Cavanagh PR, Caputo GM. Foot problems in diabetes: an overview. Clin Infect Dis 2004;39(Suppl 2):S73–S82.
Mueller MJ. Identifying patients with diabetes who are at risk for lower extremity complications: use of Semmes-Weinstein monofilaments. Phys Ther 1996;76(1):68–71.
Smieja M, Hunt DL, Edelman D, Etchells E, Cornuz J, Simel DL. Clinical examination for the detection of protective sensation in the feet of diabetic patients. International Cooperative Group for Clinical Examination Research. J Gen Intern Med 1999;14(7):418–424.
Armstrong DG. Loss of protective sensation: a practical evidence-based definition. J Foot Ankle Surg 1999;38(1):79–80.
Mason J, O’Keeffe C, Hutchinson A, McIntosh A, Young R, Booth A. A systematic review of foot ulcer in patients with Type 2 diabetes mellitus. II: treatment. Diabet Med 1999;16(11):889–909.
Young MJ, Breddy JL, Veves A, Boulton AJ. The prediction of diabetic neuropathic foot ulceration using vibration perception thresholds. A prospective study. Diabetes Care 1994;17(6):557–560.
Boulton AJM. The importance of abnormal foot pressure and gait in causation of foot ulcers, in The Foot in Diabetes (Connor H, Boulton AJM, Ward JD, eds.) 1st ed. John Wiley and Sons, Chilchester, 1987, pp. 11–26.
Duckworth T, Betts RP, Franks CI, Burke J. The measurement of pressure under the foot. Foot Ankle 1982;3:130.
Birke JA, Novick A, Graham SL, Coleman WC, Brasseaux DM. Methods of treating plantar ulcers. Phys Ther 1991;71(2):116–122.
Veves A, Murray HJ, Young MJ, Boulton AJM. The risk of foot ulceration in diabetic patients with high foot pressure: a prospective study. Diabetolgica 1992;35:660–663.
Grant WP, Sullivan R, Sonenshine DE, et al. Electron microscopic investigation of the effects of diabetes mellitus on the Achilles tendon. J Foot Ankle Surg 1997;36(4):272–278; discussion 330.
Rosenbloom AL, Silverstein JH, Lezotte DC, Riley WJ, Maclaren NK. Limited joint mobility in diabetes mellitus of childhood: natural history and relationship to growth impairment. J Pediatr 1982;101(5):874–878.
Rosenbloom AL. Skeletal and joint manifestations of childhood diabetes. Pediatr Clin North Am 1984;31:569–589.
Birke JA, Franks D, Foto JG. First ray joint limitation, pressure, and ulceration of the first metatarsal head in diabetes mellitus. Foot Ankle 1995;16(5):277–284.
Frykberg RG, Lavery LA, Pham H, Harvey C, Harkless L, Veves A. Role of neuropathy and high foot pressures in diabetic foot ulceration [In Process Citation]. Diabetes Care 1998;21(10):1714–1719.
Fernando DJS, Masson EA, Veves A, Boulton AJM. Relationship of limited joint mobility to abnormal foot pressures and diabetic foot ulceration. Diabetes Care 1991;14:8–11.
Armstrong DG, Stacpoole-Shea S, Nguyen HC, Harkless LB. Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. J Bone Joint Surg Am 1999;81A:535–538.
Birke J, Cornwall MA, Jackson M. Relationship between hallux limitus and ulceration of the great toe. Sports Phys Ther J Orthop 1988;10:172–176.
International working group on the diabetic foot. International Consensus on the Diabetic Foot. International Working Group on the Diabetic Foot, Maastricht, 1999.
Rith-Najarian S, Branchaud C, Beaulieu O, Gohdes D, Simonson G, Mazze R. Reducing lower-extremity amputations due to diabetes. Application of the staged diabetes management approach in a primary care setting. J Fam Pract 1998;47(2):127–132.
Armstrong DG, Lavery LA, Harkless LB. Who’s at risk for diabetic foot ulceration? Clin Podiatr Med Surg 1998;15:11–19.
Mayfield JA, Reiber GE, Nelson RG, Greene T. A foot risk classification system to predict diabetic amputation in pima indians. Diabetes Care 1996;19(7):704–709.
Altman MI, Altman KS. The podiatric assessment of the diabetic lower extremity: special considerations. Wounds 2000;12(Suppl B):64B–71B.
Boike AM, Hall JO. A practical guide for examining and treating the diabetic foot. Cleve Clin J Med 2002;69(4):342–348.
Macfarlane RM, Jeffcoate WJ. Factors contributing to the presentation of diabetic foot ulcers. Diabet Med 1997;14(10):867–870.
Murray HJ, Young MJ, Hollis S, Boulton AJ. The association between callus formation, high pressures and neuropathy in diabetic foot ulceration. Diabetic Med 1996;13(11):979–982.
Young MJ, Cavanagh PR, Thomas G, Johnson MM, Murray H, Boulton AJ. The effect of callus removal on dynamic plantar foot pressures in diabetic patients. Diabet Med 1992;9(1):55–57.
Pitei DL, Foster A, Edmonds M. The effect of regular callus removal on foot pressures. J Foot Ankle Surg 1999;38(4):251–255; discussion 306.
Collier JH, Brodbeck CA. Assessing the diabetic foot: plantar callus and pressure sensation. Diabetes Educ 1993;19(6):503–508.
Rosen RC, Davids MS, Bohanske LM, Lemont H. Hemorrhage into plantar callus and diabetes mellitus. Cutis 1985;35(4):339–341.
Ahroni JH, Boyko EJ, Forsberg RC. Clinical correlates of plantar pressure among diabetic veterans. Diabetes Care 1999;22(6):965–972.
Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation (see comments). Diabetes Care 1998;21(5):855–859.
Reiber GE, Pecoraro RE, Koepsell TD. Risk factors for amputation in patients with diabetes mellitus: a case control study. Ann Intern Med 1992;117(2):97–105.
Peripheral arterial disease in people with diabetes. Diabetes Care 2003;26(12):3333–3341.
Gregg EW, Sorlie P, Paulose-Ram R, et al. Prevalence of lower-extremity disease in the US adult population >=40 years of age with and without diabetes: 1999-2000 national health and nutrition examination survey. Diabetes Care 2004;27(7):1591–1597.
Edmonds ME. Experience in a multidisciplinary diabetic foot clinic, in The Foot in Diabetes (Connor H, Boulton AJM, Ward JD, eds.). John Wiley and Sons, Chichester, 1987, pp. 121–131.
Thompson FJ, Veves A, Ashe H, et al. A team approach to diabetic foot care—the Manchester experience. Foot 1991;1:75–82.
American Diabetes Association. Consensus Development Conference on Diabetic Foot Wound Care. Diabetes Care 1999;22(8):1354.
Weitz JI, Byrne J, Clagett GP, et al. Diagnosis and treatment of chronic arterial insufficiency of the lower extremities: a critical review. Circulation 1996;94(11):3026–3049.
Holstein P, Lassen NA. Healing of ulcers on the feet correlated with distal blood pressure measurements in occlusive arterial disease. Acta Orthop Scand 1980;51(6):995–1006.
Orchard TJ, Strandness DE. Assessment of peripheral vascular disease in diabetes: report and recommendation of an international workshop. Diabetes Care 1993;83(12):685–695.
Franzeck UK, Talke P, Bernstein EF, Golbranson FL, Fronek A. Transcutaneous PO2 measurements in health and peripheral arterial occlusive disease. Surgery 1982;91(2):156–163.
Grayson ML, Balaugh K, Levin E, Karchmer AW. Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients. J Am Med Assoc 1995;273(9):721–723.
Birke JA, Novick A, Patout CA, Coleman WC. Healing rates of plantar ulcers in leprosy and diabetes. Lepr Rev 1992;63(4):365–374.
Wunderlich RP, Peters EJ, Armstrong DG, Lavery LA. Reliability of digital videometry and acetate tracing in measuring the surface area of cutaneous wounds. Diabetes Res Clin Pract 2000;49(2-3):87–92.
Oyibo SO, Jude EB, Tarawneh I, et al. A comparison of two diabetic foot ulcer classification systems. Diabetes 2000;49 (Suppl 1):A33.
Armstrong DG, Peters EJ. Classification of wounds of the diabetic foot 2001;1:233–238.
Shea JD. Pressure sores: classification and management. Clin Orthop Relat Res 1975;112:89–100.
Doughty D. Management of pressure sores. J Enterostomal Ther 1984;15(1):39–44.
Yarkony GM, Kirk PM, Carlson C, et al. Classification of pressure ulcers. Arch Dermatol 1990;126:1218–1219.
Meggitt B. Surgical management of the diabetic foot. Br J Hosp Med 1976;16:227–332.
Wagner FW. The dysvascular foot: a system for diagnosis and treatment. Foot Ankle 1981;2:64–122.
Smith RG. Validation of Wagner’s classification: a literature review. Ostomy Wound Manage 2003;49(1):54–62.
Calhoun JH, Cantrell J, Cobos J, et al. Treatment of diabetic foot infections: Wagner classification, therapy, and outcome. Foot Ankle 1988;9:101–106.
Van Acker K. The Diabetic Foot. A Challenge for Policy-Makers and Health Care Professionals. Department of Medicine, University of Antwerp, Antwerp, 2000.
Forrest RD, Gamborg-Neilsen P. Wound assessment in clinical practice: a critical review of methods and their application. Acta Med Scand 1984;687:69–74.
Pecoraro RE, Reiber GE. Classification of wounds in diabetic amputees. Wounds 1990;2(2):65–73.
Arlt B, Protze J. [Diabetic foot]. Langenbecks Arch Chir Suppl Kongressbd 1997;114:528–532.
Knighton DR, Ciresi KF, Fiegel VD, Austin LL, Butler EL. Classification and treatment of chronic nonhealing wounds: successful treatment with autologous platelet-derived wound healing factors (PDWHF). Ann Surg 1986;204:332–330.
Jeffcoate WJ, Macfarlane RM, Fletcher EM. The description and classification of diabetic foot lesions. Diabetic Med 1993;10:676–679.
Pratt TC. Gangrene and infection in the diabetic. Med Clin North Am 1965;40:987–992.
LoGerfo FW, Coffman JD. Vascular and microvascular disease of the foot in diabetes. N Engl J Med 1984;311:1615–1619.
Bacharach J, Rooke T, Osmundson P, Glovizzki P. Predictive value of trascutaneous oxygen pressure and amputation success by use of supine and elevation measurements. J Vasc Surg 1992;15:558–563.
Caputo GM. Infection: investigation and management, in The Foot in Diabetes (Boulton AJM, Connor H, Cavanagh PR, eds.) 2nd ed. Wiley and Sons, Chichester, 1994.
Carter S. Elective foot surgery in limbs with arterial disease. Clin Orthop 1993;289:228–236.
Apelqvist J, Castenfors J, Larsson J. Prognostic value of ankle and toe blood pressure levels in outcome of diabetic foot ulcers. Diabetes Care 1989;12:373–378.
Joseph WS. Handbook of Lower Extremity Infections. 1st ed. Churchill Livingston, New York, 1990.
Lavery LA, Armstrong DG, Quebedeaux TL, Walker SC. Puncture wounds: the frequency of normal laboratory values in the face of severe foot infections of the foot in diabetic and non-diabetic adults. Am J Med 1996;101:521–525.
Molinar DM, Palumbo PH, Wilson WR, Ritts RE. Leukocyte chemotaxis in diabetic patients and their first degree relatives. Diabetes 1976;25:880–889.
Bagdade JD, Root RK, Bulger RJ. Impaired leukocyte function in patients with poorly controlled diabetes. Diabetes 1974;23:9–17.
Tan JS, Anderson JL, Watanakunakorn C, Phair JP. Neutrophil dysfunction in diabetes mellitus. J Lab Clin Med 1975;85:26–33.
Armstrong DG, Lavery LA, Sariaya M, Ashry H. Leukocytosis is a poor indicator of acute osteomyelitis of the foot in diabetes mellitus. J Foot Ankle Surg 1996;35(4):280–283.
Armstrong DG, Perales TA, Murff RT, Edelson GW, Welchon JG. Value of white blood cell count with differential in the acute diabetic foot infection. J Am Podiatr Med Assoc 1996;86(5):224–227.
Armstrong DG, Lavery LA, Liswood PJ, Todd WF, Tredwell JA. Infrared dermal thermometry for the high-risk diabetic foot. Phys Ther 1997;77(2):169–175; discussion 176-167.
Armstrong DG, Liswood PJ, Todd WF, William J. Stickel Bronze Award. Prevalence of mixed infections in the diabetic pedal wound. A retrospective review of 112 infections. J Am Podiatr Med Assoc 1995;85(10):533–537.
Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJ. A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems. Diabetes Care 2001;24(1):84–88.
Schaper NC. Diabetic foot ulcer classification system for research purposes: a progress report on criteria for including patients in research studies. Diabetes Metab Res Rev 2004;20(Suppl 1):S90–S95.
Macfarlane RM, Jeffcoate WJ. Classification of diabetic foot ulcers: the S(AD) SAD system. Diabetic Foot 1999;2(4):123–131.
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2006 Humana Press Inc., Totowa, NJ
About this chapter
Cite this chapter
Wu, S., Armstrong, D.G., Lavery, L.A., Harkless, L.B. (2006). Clinical Examination of the Diabetic Foot and the Identification of the At-Risk Patient. In: Veves, A., Giurini, J.M., Logerfo, F.W. (eds) The Diabetic Foot. Contemporary Diabetes. Humana Press. https://doi.org/10.1007/978-1-59745-075-1_11
Download citation
DOI: https://doi.org/10.1007/978-1-59745-075-1_11
Publisher Name: Humana Press
Print ISBN: 978-1-58829-610-8
Online ISBN: 978-1-59745-075-1
eBook Packages: MedicineMedicine (R0)