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A Pictorial Guide to Diabetic Foot Screening

Foot Screening Competency

Screening for the risk of foot ulceration and related complications in people with diabetes can be undertaken by any ‘competent’ person. Below is a list of professional activities that anyone undertaking foot screening can use as a self-assessment for competency and should identify any gaps in knowledge or experience which will help inform a personalised development plan.

 

Click each step below to expand for more information:

Knowledge

 

  • •  A general knowledge of the nature of diabetes, including its signs and symptoms.
  •  
  • •  Recognises the limits of own knowledge about diabetes.
  • •  Aware of national guidance for the diagnosis and management of diabetes.
  •  
  • •  A basic understanding of the psychological impact on the patient and/or carer of having a long-term condition.
  •  

Skills

 

  • •  Uses relevant patient record systems and decision support tools.
  •  
  • •  Undertakes protocol-led clinical examinations within the scope of their practice. 
  • •  Communicates to patients the benefits of good glycaemic control, self care and monitoring to prevent diabetic complications.

 

Behaviours

 

  • •  Refers to, and seeks guidance from, appropriately experienced colleagues when necessary.
  •  
  • •  Constructively supports changes to improve unhealthy patient lifestyles.
  •  
  • •  Utilises available professional networks for support, reflection and learning.
  •  
  • •  Takes responsibility for their own continuing professional development.

 

Screening

 

  •   •  Clearly communicates what is involved in the screening process to the patient.
  •  
  •   •  Carries out diabetic foot screening in line with national guidance and/or local protocols.
  •  
  •   •  Assigns an ulcer risk score based on the results of the screening, using relevant decision making tools when available.
  •  
  •   •  Records the screening results on the relevant patient records system/s.
  •  
  •   •  Explains the results of the screening to the patient and/ or carer in an appropriate manner.
  •  
  •   •  Provides up-to-date verbal and written advice relevant to the risk status resulting from foot screening.
  •  
  •   •  Aware of, and appropriately uses, local referral pathways

Complications

   

  •   •  Understands how the complications of diabetes increase the risk of foot ulceration.
  •  
  •   •  Understands the necessity of urgent referral and treatment in the event of suspected infection, ulceration or critical limb ischaemia.
  •  
  •   •  Understands how the complications of diabetes mean that a wound on the foot must be seen by a suitably skilled colleague with access to a multi disciplinary team as a matter of urgency.
  •  
  •   •  Encourages the patient and/or carer to comply with instructions on the use of pressure-relieving devices for the treatment of active ulceration.
  •  
  •   •  Carries out dressing changes as instructed and within the scope of their practice.

  •  
  •   •  Encourages the patient and/or carer to comply with recommended dressing regimens.
  •  
  •   •  Follows instruction from colleagues to ensure Charcot Neuropathy care plans are carried out, within the scope of their practice.

 

Who is this guide for?

This guide will support clinicians and healthcare workers undertaking a foot examination for someone with either Type 1 or Type 2 Diabetes. The national best practice guidance (NICE NG19) states that anyone performing a foot check or examination for the purpose of identifying risk of ulceration should be competent to do so. This guide will be an aide memoire for any health professional who has received competency training.

Why is this guide important?

In 2019, there were 185 amputations each week in England (around 330 per year in Wales) and it is estimated 80% are likely to be preventable. A foot ulcer precedes an amputation in around 80% of cases and is associated with significant increases in cardio-vascular mortality, depression and substantial reductions in quality-of-life measures. 50% of patients with diabetes who have a foot ulcer die within 5 years of suffering that ulceration.

Every patient in England & Wales should undergo an annual foot check and screening for foot problems. Each patient with diabetes should be assessed for their risk of developing a foot ulcer. The risk levels are Low risk, Moderate/Increased risk, High risk and Active (where there is an ulceration).

Identifying the risk of foot ulceration early and informing the patient, with appropriate advice are essential prevention actions. Studies show that timely referral to specialist clinics can save limbs and lives as well as being a professional regulation responsibility.

 

What does the National Guidance say?

NICE guideline NG19 sets out a list of the checks required to be carried out during a foot examination for someone with diabetes. A good foot examination enables accurate risk identification and gives details of the actions that should follow depending on the findings identified.

There will be a local foot pathway for referral into the Podiatry led Foot Protection Service (FPS) or the hospital based Multi Disciplinary Foot Services (MDFS). If there is any difficulty finding out this information the local NHS Podiatry Service will be able to help with contacts and pathway details. A conversation is worthwhile to understand the podiatry service contract, which may have some access limitations for foot care. www.nice.org.uk/guidance/ng19.

 

What risk factors need identification?

If the screening identifies one risk factor, (the presence of neuropathy or absence of foot pulses or a foot deformity) then a moderate/increased level is recorded. If two or more of these risk factors are identified, then a high-risk status is recorded. Naturally, if an ulcer is present then it is classified as an active wound.

Carrying out Foot Screening on a patient with diabetes

A structured approach to each foot examination will produce a more consistently accurate risk classification and save time.

 

  1. 1. Be prepared.
  •  a. Ensure you have access to a room which is comfortable for you both so that you can see, feel and examine all areas of their exposed bare feet.
  • b. You will need a 10 gram monofilament.
  • c. Have a range of foot health information available so that you can provide appropriate advice.
  • d. Ensure that you are familiar with the local foot pathway contact and referral details in case they are needed.
  • e. Familiarise yourself with the patients previous foot risk level, previous structured education and advice and their current HbA1c

  • f.  Is the patient known to be regular smoker?
  • g. Are there any known language, cultural, physical or mental health issues that may influence communication during the foot examination?

 

  • 2. Observe.
  • a. Mobilty
  • b. Size and weight
  • c. Footwear style
  • d. Swelling or oedema within legs and feet
  • e. How easily the patient can remove shoes, hosiery and any dressings that may be present.

3. The examination or foot check.

  • a. The purpose of the foot check is to screen for risk of ulceration so record the presence or absence of any of the visible risk factors such as callus, skin and nail conditions, athletes foot, fungal nails or psoriasis, deformity, pressure points, ulceration, infection or gangrene.

 

  • b. Explain to the patient what you are going to do and what will happen at the end of the examination.

 

  • c. With a good view of both legs below the knee make a visual inspection of the front and back of each limb, paying particular attention to the hard to see areas such as heels and between the toes.

  • d. Check both foot pulses on each foot by hand.
  • e. Test for changes to sensation using the monofilament.

4. Risk classification.

  • a. On completion of the foot check, any risk factors will have been identified. The patients’ risk status should be recorded, and the patient informed appropriately.

  • b. Refer to local guidance for referral on to specialist services
  • c. Where nail and skin conditions are present but sensation and circulation are adequate the patient should be recorded as low current risk and may need help with footcare.

 

  Effective Foot Checks

1. Promote early detection of foot complications.

2. Identify a personal foot ulcer risk classification.

3. Match clinical risk with appropriate actions, advice and referral.

4. Influence the outcome for the patient based on your competence and communication.

Initial Visual Inspection


Skin & Nails

Maintaining skin integrity is an essential part of good foot care for all people with diabetes. Check carefully for any changes to the skin and nails and manage accordingly. Where toes are bunched or stiff take particular care when looking between them as the skin can tear easily.
These photos show common skin conditions and we offer advice
on what to do when you see them.

If any dermatological conditions are found in association with neuropathy or poor circulation referral into the foot pathway should be made, otherwise the Practice would give advice or prescribe appropriate care.



What to look for

Blisters
A blister is a sign of trauma and understanding why this happened is important - is it functional, work related, or footwear related? Identification of the cause is essential and the Podiatry or Foot Protection Service (FPS) would need to assess in more detail.

Nail Health
Thickened, ingrown or neglected toe nails are all potential causes of skin damage. Poor nail health in a person with diabetes who is at risk of ulceration may indicate poor diabetes care. Again the FPS would assess and advise.

Athletes Foot
This is a fungal condition commonly found between the toes or on skin and nails. The irritation and skin changes can lead to breaks in the skin or can infect an existing wound.

Eczema and Psoriasis
Any patient presenting with Eczema or Psoriasis should be prescribed an appropriate treatment.

 

 

Skin & Nails Continued

 

What to look for

Callus/Corns/Verrucae
Callus is thickened skin, usually formed by increased pressure.

A corn is a concentrated area of hard skin. A common treatment for corns are corn plasters in which the active ingredient is salicylic acid.
All patients with diabetes should be advised not to use corn plasters.

A verruca is a wart on the foot. It is the result of a viral infection (human papilloma virus).

Dry skin – the patient with diabetes is more likely to suffer with dry skin. When the skin dries, it often becomes itchy and flaky. Peripheral neuropathy can cause the sweat glands to malfunction resulting in dry and cracked skin.

 

 

What to do
Always look for a cause of corns or hard skin and examine more closely in case there is any inflammation or bleeding below the skin. Is this ‘extra’ skin caused by a change in foot shape, tight shoes or occupation?

Callus and corns are always indicative of skin trauma and, if allowed to continue, are likely to lead to an ulcer or infection.


Dry foot skin is one of the most common complications associated with diabetes and needs long term management with an effective emollient.

 

 

Callus (Hyperkeratosis)

According to NICE Guideline NG19 (Diabetic Foot Problems), in the absence of other risk factors, callus or hard skin is not in itself a risk factor. However, when combined with neuropathy or poor blood supply or a foot deformity, callus itself becomes a risk factor.
Many papers have demonstrated callus in a neuropathic foot can be a leading cause of foot ulcers.

 

What to look for
For correct identification of callus the Skin Scale can be used (see below). This photographic scale was created by Dr Matthew Young and Mike Townson. The article presenting the Skin Scale was published in 2014, The Diabetic Foot Journal.

Callus can occur wherever there is pressure beneath the foot. When grading the callus, use the worst piece of callus on the foot.

 

What to do
Urea is a Natural Moisturising Factor within human skin. It promotes water retention and helps maintain hydration levels. There is a wealth of good evidence supporting the use of urea in topical applications on the diabetic foot.

When using a product with urea as an active ingredient, if the % is below 20% then the product is regarded as a moisturiser, promoting hydration levels within the skin. If the % is above 20%, the product becomes keratolytic meaning it helps to safely remove callus.

In trials carried out in the Scottish Highlands and Whittington (London), patients’ callus was identified using the Skin Scale, were issued with
Dermatonics Heel Balm (25% urea) and asked to apply the Balm just Once A Day.


Optimal emollient treatment and prevention of diabetic foot complications – Bowen G, Bristow I, Chadwick P, Edmonds M, Kedia N, Leigh R, Welch D, Walker I, Warren T & Wylie D.

Diabetic Foot Journal Vol 24, March 2021

A round table discussion resulted in the following recommendations:

All people with diabetes and hyperkeratosis require daily application of urea-based cream for use on their feet.

All people with diabetes and peripheral neuropathy require daily application of urea-based cream for use on their feet.

All people with diabetes and hyperkeratosis & peripheral neuropathy require daily application of urea-based cream for use on their feet.

People with diabetes requiring urea-based emollient should have it made available via prescription.

 

 

 

Neuropathy

 

What to look for
Lack of sensation in the feet - If a patient is unable to feel a 10g monofilament, they are deemed to have lost protective sensation.

How to check
Begin by asking if there is any history of restless legs, tightness, tingling or irritation in legs and feet.

Prior to assessing the foot sensation, demonstrate to the patient that the monofilament is not sharp by applying it to your own forearm. In addition, allow the patient to feel the pressure on their arm or hand so they understand what they should be feeling.

Extra sites can be tested if the minimum sites are inappropriate or impossible to test ( For example, if the big toe has been amputated). Check you local guidelines as many areas use 5 sites per foot. It is never a mistake to test additional sites.

The absence of protective sensation at even a single site indicates the presence of peripheral neuropathy; that’s why it’s an important part of the test.

 


What to do
Loss of protective pain sensation is an indicator of neuropathy and places a person with diabetes at significant risk of active foot disease. The reduction or loss of pain can reduce the stimulation to check feet daily so reinforcing and supporting education is critical at this stage. As well as changes is sensation neuropathy will lead to changes in foot shape leading to pressure areas and skin dryness resulting in cracks in the skin.

These changes add up to a foot at HIGH risk of ulceration so refer to a specialist team immediately.

 

Pulses

 

The foot contains two pulses in arteries bringing blood into the area.

Tibialis Posterior: To palpate pulse, place fingers behind and slightly below the medial malleolus of the ankle. In an obese or oedematous ankle, the pulse may be more difficult to feel.

Dorsalis Pedis: To palpate pulse, place index and middle fingers just lateral to the extensor tendon of the great toe, usually between the 1st and 2nd metatarsal. If you cannot feel a pulse, move fingers more laterally.

To enhance technique: Assume a comfortable position for you and the patient. Place hand in position and linger on the site.
Varying pressure may assist in picking up a weak pulsation. Always keep your thumb away from the process, as it is likely to transmit your own pulse pressure and cause confusion.

 


What to do
Regularly practice feeling foot pulses so they become familiar, its always a good health check and may help identify people with circulatory conditions or undiagnosed diabetes. There is no need to use a Doppler for this ‘screening’ process.

If you cannot feel a pulse the patient is likely to need further assessment and this could help early detection of Peripheral Arterial Disease, which is a key cardio vascular risk indicator.

Always take absent pulses seriously and refer, particularly if associated with other symptoms such as intermittent claudication, rest pain, neuropathy and hard skin.

Poor circulation in association with a foot wound is a Foot Attack clinical emergency and needs immediate vascular assessment.

 

Deformity

 

Deformity is defined as a change in foot shape that results in difficulty in fitting standard shoes and is subjectively assessed by the practitioner. Clearly this is a flexible definition and a good visible inspection will identify any changes in alignment between the foot and ankle joints.

In the forefoot the presence of common conditions such bunions, hammer or clawed (retracted) toes are all deformities, which will
create trauma to foot skin tissue, which must be avoided particularly in association with loss of protective sensation and poor foot pulses.

What to look for
Check the suitability of the patient’s footwear, especially if they are showing signs of shoe pressure. Check inside the shoe:

    • Is the lining worn or cracked?
    • Are there any rough seams?
    • Are there any foreign objects that have gone unnoticed?
    • Is the style and the shape of the shoe suitable for daily wear?


What to do
Patients should be advised to wear a shoe that fastens to increase stability and prevent friction. Their shoes should also be wide and deep enough to accommodate any deformities of the patient’s feet. Heel height should be kept to a minimum.

Always advise on suitable footwear and use information from Diabetes UK.

Bespoke footwear is an important part of ulcer prevention and may be prescribed once the patient has been referred into the foot pathway.

 

Infection or Inflammation

 

What to look for
Early identification, action and referral for all foot infection with diabetes is essential to protect limb and life.

Bacterial infection can rapidly devastate soft tissues and deeper infections may affect bone leading to osteomyelitis.
 
Sepsis and cellulitis are associated complications that may
lead from a small foot wound.

Inflammation is an early sign of infection and should always be taken seriously. The nature of ageing, peripheral neuropathy and limb ischaemia is to suppress the inflammatory response and so an infected foot may not present with the classic signs of redness, swelling and heat.
So be suspicious and check for puncture wounds, compare foot temperature and take a good history. Any exudate of typical bacterial odour must prompt very close inspection.

Other infections such as fungal, typically on nails or between toes can delay wound healing and need to be managed as part of preventative care.


What to do
Whenever there is a concern of deep-seated soft tissue or bone infection (with or without ulceration) refer immediately to acute services and inform the multidisciplinary foot care service according to local
protocols and pathways.

Be aware of your local antibiotic guidelines for diabetic foot infection.

 

Ulceration

 

What to look for
By definition, an ulcer is “A localised injury to the skin/underlying tissue, below the ankle, in a person with diabetes” (NICE guideline NG19- Diabetic Foot Problems). Within the International Working Group for the Diabetic Foot (IWGDF) an ulcer is defined as “A break of the skin that includes minimally the epidermis and part of the dermis”.

Ulcers develop within subcutaneous tissue so may not be seen until they ‘break through’ into an open wound. Preulcerative callus lies over such wounds in 80% of cases. In 1996 Murray et al stated, “the presence of plantar callus is highly predictive of subsequent ulceration”. In pre-ulcerative callus, the skin tissue may appear soft or spongy. There may
also be signs of subcutaneous haemorrhage.

Very often, the true extent of a foot ulcer is only fully appreciated after sharp debridement. Trauma is often the trigger so, the screener must take a good history and undertake a close inspection of the feet as a patient with neuropathy may not be aware of any incident or injury. Ulcers
can occur under nails and around the back of heels so it is important the screener carries out a full examination of the patients’ feet.

What to do
In the event of finding or suspecting a diabetic foot ulcer, the patient must be referred immediately to a Multi-Disciplinary Foot Service (MDFS) for medical and wound assessment.

NICE Guidelines dictate this ought to be done within 24 hours of finding the wound.

Best practice for wound classification is the SINBAD system:

S - Site
I - Ischaemia
N - Neuropathy
B - Bacterial infection
A - Area
D - Depth

 

 

Gangrene

 

What to look for
A good foot inspection will identify any changes in colour and temperature. Gangrene is evidence of critical limb ischaemia and tissue death and is most likely to affect toes or heel if bed bound.

Characterised by loss of colour, eventually turning dry and dark, going through red to black color in dry gangrene, or being swollen and foulsmelling in wet gangrene where it is associated with infection.

The foot will have a shiny appearance, shedding of skin tissue with a distinct line forming between affected and healthy skin. The affected area of the foot will be cold due to lack of blood flow. Initial pain is later followed by loss of sensation and an inability to move the part.

 


What to do
Gangrene is a limb and life-threatening condition and requires immediate referral for acute vascular assessment. Inform the multidisciplinary foot care service (according to local protocols and pathways) so the patient
can be assessed, and an individualised treatment plan put in place.

 

Charcot Foot

Charcot foot (arthropathy) is a condition causing weakening of the bones in the foot that can occur in people who have significant nerve damage (neuropathy).

The bones are weakened enough to fracture, and with continued walking the foot eventually changes shape. As the disorder progresses, the joints collapse and the foot takes on an abnormal shape, such as a rocker-bottom appearance.

If the patient has reduced sensation, they may be unaware of the trauma and not reduce their activity levels, leading to further destruction and damage to the foot.


What to look for
Suspect acute Charcot arthropathy if there is redness, warmth, swelling or deformity (in particular, when the skin is intact), especially in the presence of peripheral neuropathy or renal failure. Think about acute Charcot arthropathy even when deformity is not present or pain is not reported.

 

What to do
To confirm the diagnosis of acute Charcot arthropathy, refer the person within 1 working day to the multidisciplinary footcare service for triage within 1 further working day. Advise non- weight-bearing until definitive diagnosis and treatment can be started.

This complication is not common but failure to recognise and/or refer can have devastating implications on mobility and well being.