Circulation (macro circulation)

1. Dorsalis Pedis - Palpate the top of the
foot between the first and second
metatarsal. - (note whether present or
absent).

NB
Dorsalis pedis is
absent in 10% of the
population.

2. Posterior tibial - Palpate the area behind
the medial malleolus (ankle bone) - (note
whether present or absent).
If either pulse can be felt then it is unlikely
that there is significant ischaemia.

3. Repeat for other foot.

4. If pulses are difficult to palpate / absent,
and / or there are other signs of poor
circulation (colour, temperature, thin
atrophic shiny skin) then ascertain if
the patient is experiencing any symptoms
of intermittant claudication (pain or
tightness in the calves when walking,
relieved by stopping) or rest pain.

5. Symptoms of intermittent claudication /
rest pain should be noted in the patients
notes.

“Absent pulses may indicate ischaemia which should be further evaluated by a Podiatrist or Doctor.”

10 g Monofilament

1. Tell the patient that you are going to test their sensation in their feet. Before testing on the feet, demonstrate the mono?lament on the back of their hand / arm telling the patient that it is not sharp before you do so.
   
2. Apply the monofilament perpendicular to the surface of the skin and apply suf?cient force to bend the ?lament. Do not make repetitive contact or allow the ?lament to slide across the skin.
   
3. The approach, skin contact and departure of the monofilament should be approximately 1.5 seconds duration.
   
4. Ask the patient to close their eyes and respond ‘yes’ each time they feel it on their foot.
   
5. The sites to be tested are indicated in the photograph opposite.
   
6. Randomise the order and timing of successive tests (to reduce the potential for patient guessing).
   
7. Do not apply to an ulcer site, callous, scar or necrotic tissue.
   
8. Patient is ‘at risk’ if they score 8 or less out of a total of 10 sites.
   
9. Record results on screening form.
   
10. Refer to podiatry if appropriate.

Care of Monofilaments
Monofilaments should be replaced approximately every 6 months (dependant on frequency of use) or if the monofilament becomes kinked.
Only use approved monofilaments, ‘freebies’ from drug reps are not always accurate to 10gms pressure.

Neurotip

• Demonstrate the sharp and blunt ends of the neurotip on the back of the patients hand.
• Ask the patient to close their eyes and tell you which feels sharper, the 1rst or second.
• Apply sharp and blunt ends of the neurotip (in random order) to the apex of the left big toe and then the right.
• Record if normal or impaired.

Symptoms of Painful Neuropathy

• Ask if experiencing pins and needles / burning
  sensation in feet.
• If symptoms persistent and patient not currently receiving treatment, inform G.P

The foot should be fully inspected including the top, sole, back of the heel and in between the toes.

Colour Which may be:

• Normal
• Red and hot, which may indicate the presence of infection, cellulitus or Charcot’s foot (especially if unilateral).
• Dusky red, pale and mottled or blue and cyanotic, indicating ischaemia. Patchy gangrene may also be present on the apices of the toes.

Temperature gradient

• Using the back of the hand move from the front of the shin down to the foot.
• A gradual temperature gradient is normal, cooling towards the foot.
  
  Marked or abrupt alteration this may indicate a problem with the circulation.

Hair growth

• Observe the hair growth on the foot and shin. Lack of hair growth may indicate reduced circulation.

Skin

• Examine for callus -(check for dark areas under callus) and corns.
• Observe quality of skin, dry and cracked, thin and shiny, atrophy of planter fat pad.
• Look for open wounds, blisters, ulcers.
• Look for signs of athletes foot, especially between the toes.
• Check around the heel for dry, fissured callus.Advise daily use of emollient and avoid wearing open back shoes.

Nails

• Check for nail abnormalities that may make self care dificult eg - thickened / involuted nails.

Foot shape

Observe for deformity such as bunions,
clawed toes, very wide or swollen feet that
could make shoe fitting difficult with standard
footwear.

Shoes

Check for suitability, especially if the foot is
showing signs of shoe pressure (eg corns
or callus on the top of the toes, red pressure
marks, indentations where the shoe is cutting
into the foot).

Look at the shoes

• Are they being pushed out of shape?
• Check inside
• Is the lining worn or cracked?
• Are there rough seams?
• Is the style and shape of the shoe suitable
  for daily wear?

Give (or reinforce) general education for low risk patients and give Low Risk Foot education leaflet.

Footwear

Shoes that are the wrong style or poorly
fitting are major contributors to diabetic foot ulceration. Therefore advice about footwear is necessary.

Features of a bad shoe include

• Slip on style which causes pressure on the forefoot
• High heels
• Thin soled shoes

      The Good Shoe Guide:

• The toe box is roomy to avoid pressure on the toes.
• Heel fit - a snug fit here is best. The shoe should not move up and down at the back.
• Heel height - no higher than 1 inch and the wider the better.
• Shoe should fasten with lace, velcro or a strap and these should be high
  enough up the foot to hold it firmly and hold the foot back in the shoe.
• Court or slip - on shoes should be avoided except for special occasions
  *(they put a lot of pressure on the toes).
• Shoe lining should be smooth. The front of the shoe should be as plain as
  possible to avoid joins in the lining inside the shoe.
• Wearing socks / tights helps reduce friction within shoes.
• Socks with bulky seams should be worn inside - out.
• Soles should be well cushioned.
• Uppers soft leather.