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Clinical Examination and Risk Classification of the Diabetic Foot

  • Lawrence A. Lavery
  • Suzanne van Asten
  • Javier La Fontaine
Chapter
Part of the Contemporary Diabetes book series (CDI)

Abstract

A consistent, thoughtful assessment of the diabetic foot is pivotal to identify patients at risk for ulceration. In this chapter, we discuss the key risk factors to screen patients for foot complications: a history of lower extremity disease, the presence of peripheral neuropathy, and foot deformities. We discuss the practical approach and background of these key risk factors and subsequently the two most commonly used classification systems for diabetic foot ulcers. Many of the risk factors for ulceration may be identified using simple, inexpensive techniques in a primary care setting. Appropriate classification of the wound becomes paramount in our efforts to document and communicate the level of risk and facilitate amputation prevention.

Keywords

Diabetes Mellitus Foot Diabetic foot Ulcer Prevention Risk Classification Peripheral Neuropathy Foot Deformities 

References

  1. 1.
    Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2):217–28.CrossRefPubMedGoogle Scholar
  2. 2.
    Boulton AJM, Vileikyte L. Pathogenesis of diabetic foot ulceration and measurements of neuropathy. Wounds. 2000;12(Suppl B):12B–8B.Google Scholar
  3. 3.
    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. 2001;38(3):309–17.PubMedGoogle Scholar
  4. 4.
    Armstrong DG, Lipsky BA. Advances in the treatment of diabetic foot infections. Diabetes Technol Ther. 2004;6:167–77.CrossRefPubMedGoogle Scholar
  5. 5.
    Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care. 1990;13:513–21.CrossRefPubMedGoogle Scholar
  6. 6.
    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):303–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Cavanagh PR, Ulbrecht JS, Caputo GM. Biomechanical aspects of diabetic foot disease: aetiology, treatment, and prevention. Diabet Med. 1996;13(Suppl 1):S17–22.CrossRefPubMedGoogle Scholar
  8. 8.
    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):818–21.CrossRefPubMedGoogle Scholar
  9. 9.
    Lavery LA, Lavery DC, Quebedeax-Farnham TL. Increased foot pressures after great toe amputation in diabetes. Diabetes Care. 1995;18(11):1460–2.CrossRefPubMedGoogle Scholar
  10. 10.
    Brand PW. The diabetic foot. In: Ellenberg M, Rifkin H, editors. Diabetes mellitus, theory and practice. 3rd ed. New York: Medical Examination Publishing; 1983. p. 803–28.Google Scholar
  11. 11.
    Bus SA, van Netten JJ, Lavery LA, Monteiro-Soares M, Rasmussen A, Jubiz Y, et al. IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes. Diabetes Metab Res Rev. 2016;32(S1):16–24.CrossRefPubMedGoogle Scholar
  12. 12.
    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;158:158–62.CrossRefGoogle Scholar
  13. 13.
    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):1442–7.CrossRefPubMedGoogle Scholar
  14. 14.
    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):704–9.CrossRefPubMedGoogle Scholar
  15. 15.
    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):127–32.PubMedGoogle Scholar
  16. 16.
    Armstrong DG, Lavery LA, Harkless LB. Who's at risk for diabetic foot ulceration? Clin Podiatr Med Surg. 1998;15:11–9.PubMedGoogle Scholar
  17. 17.
    Monteiro-Soares M, Boyko EJ, Ribeiro J, Ribeiro I, Dinis-Ribeiro M. Risk stratification systems for diabetic foot ulcers: a systematic review. Diabetologia. 2011;54(5):1190–9.CrossRefPubMedGoogle Scholar
  18. 18.
    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):1036–42.CrossRefPubMedGoogle Scholar
  19. 19.
    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):377–84.CrossRefPubMedGoogle Scholar
  20. 20.
    Lavery LA, Peters EJ, Williams JR, Murdoch DP, Hudson A, Lavery DC. Reevaluating the way we classify the diabetic foot: restructuring the diabetic foot risk classification system of the International Working Group on the Diabetic Foot. Diabetes Care. 2008;31(1):154–6.CrossRefPubMedGoogle Scholar
  21. 21.
    Waaijman R, de Haart M, Arts MLJ, et al. Risk factors for plantar foot ulcer recurrence in neuropahic diabetic patients. Diabetes Care. 2014;37:1697–705.CrossRefPubMedGoogle Scholar
  22. 22.
    Uccioli L, Faglia E, Monticone G, et al. Manufactured shoes in the prevention of diabetic foot ulcers. Diabetes Care. 1995;18(10):1376–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Helm PA, Walker SC, Pulliam GF. Recurrence of neuropathic ulcerations following healing in a total contact cast. Arch Phys Med Rehabil. 1991;72(12):967–70.PubMedGoogle Scholar
  24. 24.
    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 Intern Med. 1998;158:289–92.CrossRefPubMedGoogle Scholar
  25. 25.
    Quebedeaux TL, Lavery LA, Lavery DC. The development of foot deformities and ulcers after great toe amputation in diabetes. Diabetes Care. 1996;19(2):165–7.CrossRefPubMedGoogle Scholar
  26. 26.
    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):204–8.CrossRefPubMedGoogle Scholar
  27. 27.
    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):157–62.CrossRefPubMedGoogle Scholar
  28. 28.
    Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in persons with diabetes. JAMA. 2005;293:217–28.CrossRefPubMedGoogle Scholar
  29. 29.
    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):115–28.CrossRefPubMedGoogle Scholar
  30. 30.
    Liniger C, Albeanu A, Bloise D, Assal JP. The tuning fork revisited. Diabet Med. 1990;7(10):859–64.CrossRefPubMedGoogle Scholar
  31. 31.
    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 neurothesiometer. Diabet Med. 2004;21(6):563–7.CrossRefPubMedGoogle Scholar
  32. 32.
    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):1077–80.CrossRefPubMedGoogle Scholar
  33. 33.
    Armstrong DG. The 10-g monofilament: the diagnostic divining rod for the diabetic foot? Diabetes Care. 2000;23(7):887.CrossRefPubMedGoogle Scholar
  34. 33.
    Sorman E, Edwall LL. [Examination of peripheral sensibility. Vibration test is more sensitive than monofilament test]. Lakartidningen 2002;99(12):1339–1340.Google Scholar
  35. 34.
    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):457–61.PubMedGoogle Scholar
  36. 35.
    Rith-Najarian SJ, Stolusky T, Gohdes DM. Identifying diabetic patients at risk for lower extremity amputation in a primary health care setting. Diabetes Care. 1992;15(10):1386–9.CrossRefPubMedGoogle Scholar
  37. 36.
    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;23:606–11.CrossRefPubMedGoogle Scholar
  38. 37.
    Yong R, Karas TJ, Smith KD, Petrov O. The durability of the Semmes-Weinstein 5.07 monofilament. J Foot Ankle Surg. 2000;39(1):34–8.CrossRefPubMedGoogle Scholar
  39. 38.
    Booth J, Young MJ. Differences in the performance of commercially available 10-g monofilaments. Diabetes Care. 2000;23(7):984–8.CrossRefPubMedGoogle Scholar
  40. 39.
    Ulbrecht JS, Cavanagh PR, Caputo GM. Foot problems in diabetes: an overview. Clin Infect Dis. 2004;39(Suppl 2):S73–82.CrossRefPubMedGoogle Scholar
  41. 40.
    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.CrossRefPubMedGoogle Scholar
  42. 41.
    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):418–24.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 42.
    Armstrong DG. Loss of protective sensation: a practical evidence-based definition. J Foot Ankle Surg. 1999;38(1):79–80.CrossRefPubMedGoogle Scholar
  44. 43.
    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):557–60.CrossRefPubMedGoogle Scholar
  45. 44.
    Abbott CA, Vileikyte L, Williamson S, Carrington AL, Boulton AJ. Multicenter study of the incidence of and predictive risk factors for diabetic neuropathic foot ulceration. Diabetes Care. 1998;21(7):1071–5.CrossRefPubMedGoogle Scholar
  46. 45.
    Sosenko JM, Kato M, Soto R, Bild DE. Comparison of quantitative sensory-threshold measures for their association with foot ulceration in diabetic patients. Diabetes Care. 1990;13(10):1057–61.CrossRefPubMedGoogle Scholar
  47. 46.
    Vileikyte L, Hutchings G, Hollis S, Boulton AJ. The tactile circumferential discriminator. A new, simple screening device to identify diabetic patients at risk of foot ulceration. Diabetes Care. 1997;20(4):623–6.CrossRefPubMedGoogle Scholar
  48. 48.
    Rayman G, Vas PR, Baker N, et al. The Ipswich touch test: a simple and novel method to identify in-patients with diabetes at risk of foot ulceration. Diabetes Care. 2011;34:1517–8.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Bowling FL, Abbot CA, Harris WE, et al. A pocket sized disposable device for testing the integrity of sensation in the outpatient setting. Diabet Med. 2012;29:1550–2.CrossRefPubMedGoogle Scholar
  50. 50.
    Sharma S, Kerry C, Atkins H, Rayman G. The Ipswich touch test: a simple and novel method to screen patients with diabetes at home for increased risk of foot ulceration. Diabet Med. 2014;31(9):1100–3.CrossRefPubMedGoogle Scholar
  51. 51.
    Duckworth T, Betts RP, Franks CI, Burke J. The measurement of pressure under the foot. Foot and Ankle. 1982;3:130.CrossRefPubMedGoogle Scholar
  52. 52.
    Birke JA, Novick A, Graham SL, Coleman WC, Brasseaux DM. Methods of treating plantar ulcers. Phys Ther. 1991;71(2):116–22.CrossRefPubMedGoogle Scholar
  53. 53.
    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;35:660–3.CrossRefGoogle Scholar
  54. 54.
    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):272–8. discussion 330CrossRefPubMedGoogle Scholar
  55. 55.
    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):277–84.CrossRefPubMedGoogle Scholar
  56. 56.
    Frykberg RG, Lavery LA, Pham H, Harvey C, Harkless L, Veves A. Role of neuropathy and high foot pressures in diabetic foot ulceration. Diabetes Care. 1998;21(10):1714–9.CrossRefPubMedGoogle Scholar
  57. 57.
    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.CrossRefPubMedGoogle Scholar
  58. 58.
    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:535–8.CrossRefGoogle Scholar
  59. 59.
    Francia P, Seghieri G, Gulisano M, et al. The role of joint mobility in evaluating and monitoring the risk of diabetic foot ulcer. Diabetes Res Clin Pract. 2015;108(3):398–404.CrossRefPubMedGoogle Scholar
  60. 60.
    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):721–3.CrossRefGoogle Scholar
  61. 61.
    Birke JA, Novick A, Patout CA, Coleman WC. Healing rates of plantar ulcers in leprosy and diabetes. Lepr Rev. 1992;63(4):365–74.PubMedGoogle Scholar
  62. 62.
    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.CrossRefPubMedGoogle Scholar
  63. 63.
    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.CrossRefPubMedGoogle Scholar
  64. 64.
    Oyibo SO, Jude EB, Tarawneh I, et al. A comparison of two diabetic foot ulcer classification systems. Diabetes. 2000;49(Suppl 1):A33.Google Scholar
  65. 65.
    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):855–9.CrossRefPubMedGoogle Scholar
  66. 66.
    Mutluoglu M, Uzun G, Sildiroglu O, Turhan V, Mutlu H, Yildiz S. Performance of the probe-to-bone test in a population suspected of having osteomyelitis of the foot in diabetes. J Am Podiatr Med Assoc. 2012;102(5):369–73.CrossRefPubMedGoogle Scholar
  67. 67.
    Lavery LA, Armstrong DG, Peters EJ, Lipsky BA. Probe-to-bone test for diagnosing diabetic foot osteomyelitis: reliable or relic? Diabetes Care. 2007;30(2):270–4.CrossRefPubMedGoogle Scholar
  68. 68.
    Armstrong DG, Peters EJ. Classification of wounds of the diabetic foot. Curr Diab Rep. 2001;1:233–8.CrossRefPubMedGoogle Scholar
  69. 69.
    Meggitt B. Surgical management of the diabetic foot. Br J Hosp Med. 1976;16:227–332.Google Scholar
  70. 70.
    Wagner FW. The dysvascular foot: a system for diagnosis and treatment. Foot and Ankle. 1981;2:64–122.CrossRefPubMedGoogle Scholar
  71. 71.
    Smith RG. Validation of Wagner's classification: a literature review. Ostomy Wound Manage. 2003;49(1):54–62.PubMedGoogle Scholar
  72. 72.
    Calhoun JH, Cantrell J, Cobos J, et al. Treatment of diabetic foot infections: Wagner classification, therapy, and outcome. Foot and Ankle. 1988;9:101–6.CrossRefPubMedGoogle Scholar
  73. 73.
    Van Acker K. The diabetic foot. A challenge for policy-makers and health care professionals. Antwerp: Department of Medicine, University of Antwerp; 2000.Google Scholar
  74. 74.
    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.Google Scholar
  75. 75.
    Pecoraro RE, Reiber GE. Classification of wounds in diabetic amputees. Wounds. 1990;2(2):65–73.Google Scholar
  76. 76.
    Arlt B, Protze J. Diabetic foot. Langenbecks Arch Chir Suppl Kongressbd. 1997;114:528–32.PubMedGoogle Scholar
  77. 77.
    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;204:332–0.CrossRefGoogle Scholar
  78. 78.
    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):S90–5.CrossRefPubMedGoogle Scholar
  79. 79.
    Macfarlane RM, Jeffcoate WJ. Classification of diabetic foot ulcers: the S(AD) SAD system. The Diabetic Foot. 1999;2(4):123–31.Google Scholar
  80. 80.
    Jeffcoate WJ, Macfarlane RM, Fletcher EM. The description and classification of diabetic foot lesions. Diabet Med. 1993;10:676–9.CrossRefPubMedGoogle Scholar
  81. 81.
    Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg. 1996;35(6):528–31.CrossRefPubMedGoogle Scholar
  82. 83.
    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 Vac Surg. 1992;15:558–63.CrossRefGoogle Scholar
  83. 84.
    Carter S. Elective foot surgery in limbs with arterial disease. Clin Orthop. 1993;289:228–36.Google Scholar
  84. 85.
    Apelqvist J, Castenfors J, Larsson J. Prognostic value of ankle and toe blood pressure levels in outcome of diabetic foot ulcers. Diabetes Care. 1989;12:373–8.CrossRefPubMedGoogle Scholar
  85. 86.
    Orchard TJ, Strandness DE. Assessment of peripheral vascular disease in diabetes: report and recommendation of an international workshop. Diabetes Care. 1993;83(12):685–95.Google Scholar
  86. 87.
    Lipsky BA, Aragon-Sanchez J, Diggle M, et al. IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes Metab Res Rev. 2016;32(S1):45–74.CrossRefPubMedGoogle Scholar
  87. 88.
    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;101:521–5.CrossRefPubMedGoogle Scholar
  88. 89.
    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):280–3.CrossRefPubMedGoogle Scholar
  89. 90.
    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):84–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Lawrence A. Lavery
    • 1
  • Suzanne van Asten
    • 1
  • Javier La Fontaine
    • 1
  1. 1.Department of Plastic SurgeryUniversity of Texas Southwestern Medical CenterDallasUSA

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