The why and how of foot assessments in diabetes

WHY FOOT ASSESSMENTS IN DIABETES?

A Diabetes UK survey in 2017 showed that 1 in 3 people with diabetes did not know that foot ulcers are a serious complication of their condition. Foot ulcers can lead to foot and leg amputations, and to early death. Amputations relating to diabetes are increasing in young and middle-aged adults in the UK.¹

An annual foot check is one of the nine core care processes for someone with diabetes and is often performed by general practice nurses.

During the pandemic, many of the care processes for people with diabetes were missed. The greatest impacts of the pandemic were on foot examination, weight measurement, and retinal screening.² Performance of these core processes remains lower than pre-pandemic levels.

Foot checks are vital to ensure patients are aware of their current foot risk score, which is an indicator of the probability of a serious foot problem.

In England, 7,957 major (above the ankle), 21,738 minor (below the ankle) diabetes related amputations and 171,759 foot-disease-related hospital admissions were reported for the period 2017/18 to 2019/20.3 Every 20 seconds a limb is lost somewhere in the world.⁴

Managing the diabetic foot, coupled with the cost of associated lower limb amputations, costs the NHS in England up to £1 billion annually.⁵ Up to 80% of diabetes-related amputations, with a 50% five-year mortality, are avoidable.⁶ The increase in volume and associated value of clinical negligence claims involving patients with diabetes-related lower limb complications is increasing and led to a report and recommendations by NHS Resolution in 2022.⁷

Foot assessments identify the presence of risk factors for foot complications in diabetes, which could lead to foot ulceration, infection and amputation. The foot assessment should determine the patient’s risk of foot problems so that the patient can be advised of their risk status and provided with relevant education for self-management and, most importantly, when to seek urgent advice.

FREQUENCY OF ASSESSMENTS

The NICE guideline on the prevention and management of diabetic foot problems [NG19] recommends that children with diabetes who are under 12 years, and their family members or carers (as appropriate), should be given basic foot care advice.⁸ For young people with diabetes who are 12 to 17 years, the paediatric care team or the transitional care team should assess the young person's feet as part of their annual assessment and provide information about foot care. If a diabetic foot problem is found or suspected, the paediatric care team or the transitional care team should refer the young person to an appropriate specialist. For adults with diabetes, assess their risk of developing a diabetic foot problem:

• When diabetes is diagnosed, and at least annually thereafter
• If any foot problems arise
• On any admission to hospital; and
• If there is any change in their status while they are in hospital.⁸

HOW TO UNDERTAKE A FOOT CHECK

1. Take a history

Record the patient’s medical, surgical and social history.

Record information about their foot care.

Ask

• How often do you check your feet?
• Have you ever had a problem with your feet?
• Have you noticed any changes to your feet such as onset of pain, change in colour, temperature or foot shape?
• Do you see a podiatrist regularly?

Record if the patient is unable to self-care, or suffers from any of the disabilities listed below, as this can increase the risk of foot problems.

• Visual impairment
• Physical impairment
• Learning difficulties
• Inability to check feet
• Inability to maintain personal hygiene

2. Perform the examination

Perform a visual inspection of both feet including heels, soles and in between the toes checking for signs of swelling, inflammation, skin colour, callus, blisters, fissures (cracks in hard skin) ulceration, deformity, nail problems, signs of infection.

Perform a vascular assessment of both feet. Palpate pulses in the feet or use a handheld doppler ultrasound which may be more reliable than palpation alone.

• Dorsalis pedis pulse (note, this pulse is not palpable in about 10% of people).
• Posterior tibial pulse

If pulses are absent the patient may require an in-depth vascular assessment to determine if there are problems with blood flow to the feet. If the patient complains of cramp in the calf when walking any distance (claudication), which is relieved by rest, this may also be a sign of peripheral arterial disease.

Perform a sensory assessment. Diabetes can cause nerve damage causing peripheral neuropathy. There may be a loss of pain sensation, loss of the awareness of hot and cold, and loss of sensation (sensory neuropathy). These sensations are normally protective mechanisms, which are alerts to tissue damage. With loss of these sensations, tissue damage, ulceration and infection can occur without the patient noticing. Despite neuropathy causing a loss of sensation, some patients have neuropathic pain with symptoms of shooting pain, numbness, burning sensations, and/or pins and needles.

• Test four sites on each foot for neuropathy using a 10g monofilament. Ask the patient to close their eyes and to respond if they feel the monofilament.
• Press the monofilament perpendicular to the skin until it buckles slightly. Test the plantar aspects of the first, third and fifth toes and the first metatarsal head. Record your findings.

Failure to feel the monofilament at any point indicates a loss of sensation and neuropathy.

Neuropathy may also cause change to foot shape such as clawing toes (motor neuropathy) and dry, cracked skin due to loss of sweating (autonomic neuropathy). These should also be considered when testing for neuropathic changes.

If a 10g monofilament is not available, the ‘Touch the Toes Test’ can be performed. This test is also known as the Ipswich Touch Test, which was designed by Gerry Rayman and the team at Ipswich Hospital.⁹

• Ask the patient to close their eyes
• Tell the patient you are going to touch their toes
• Ask them to tell you which foot you touched, left or right
• Touch first (big) toe, right foot gently for 2 seconds. Do not repeat.
• Touch fifth (little) toe, right foot, then first toe, left foot; fifth (little) toe left foot; third (middle) toe, right foot; finally third toe, left foot.
• If the patient cannot feel two or more toes, they have reduced sensation and are at risk of a diabetic foot ulcer. Their feet should be checked for ulceration and protected from pressure damage with a heel protector, e.g. Prevalon Boot.

3. Risk stratification

It is important that the patient knows their foot risk stratification. This will direct how often the patient requires foot review and the type of education they require to prevent foot problems. Risk is assessed as low risk, moderate risk, high risk and active foot problem e.g. ulceration (Table 1). Make sure your patient knows and understands their foot risk score.

4. Provide education

Tell your patient their risk score and ensure they know what this means. If they are moderate or high risk, they must be referred to their Foot Protection Service, usually provided by community podiatry services.

Patient advice to prevent foot problems for low risk feet¹⁰

• Check your feet every day for any blisters, breaks in the skin, pain or any signs of infection such as swelling, heat or redness. If you cannot do this yourself, ask your partner or carer to help you.
• Badly-fitting shoes are a common cause of irritation or damage to feet. The professional who screened your feet will give you an advice leaflet about footwear.
• Wash your feet every day in warm water and with mild soap. Rinse them thoroughly and dry them carefully, especially between the toes. Do not soak your feet as this can damage your skin.
• Moisturise your feet every day. If your skin is dry, apply a moisturising cream, avoiding the areas between your toes.
• Cut or file your toenails regularly, following the curve of the end of your toe. Use a nail file to make sure that there are no sharp edges that could press into the next toe. Do not cut down the sides of your nails as you may create a ‘spike’ of nail, which could result in an ingrown toenail.
• Change your socks, stockings or tights regularly. They should not have bulky seams and the tops should not be elasticated.
• Check the bottom of your shoes before putting them on to make sure that nothing sharp such as a pin, nail or glass has pierced the outer sole. Also, run your hand inside each shoe to check that no small objects, such as small stones, are present.
• Do not use over-the-counter corn remedies. They are not recommended for anyone with diabetes as they can be highly dangerous and can lead to new wounds and infections.
• It is important that you attend your yearly screening appointment as well as all of your regular diabetes review appointments. This reduces the risk of problems developing.

Further information about footcare in diabetes is available from the Royal College of Podiatry website – see Resources.

TIME IS TISSUE!

The national diabetes footcare audit has shown that the quicker a person with diabetes and a foot condition sees an expert the better the outcome. The longer patients wait to see a specialist, the more damage can occur to the tissues of the foot. Find out who your local Foot Protection (often community podiatry) and Multidisciplinary Footcare Teams (usually based in hospital) are and advise patients how to contact them if they have a foot problem. There are cards available in different skin tones from Insights for Diabetes Excellence, Access and Learning (iDEAL) called ‘ACT NOW’, (Figure 1) which indicate when a patient should seek urgent attention.

REFERENCES

1. NHS Digital Report 1: Care Processes and Treatment Targets 2020-21 Full Report; 2022. https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-audit/core-report-1-2020-21#

2. National Cardiovascular Intelligence Network. National Diabetes Foot Care Report: 2022.

https://fingertips.phe.org.uk/static-reports/diabetes-footcare/national-diabetic-footcare-report.html

3. D-Foot International. Foot Facts; 2024

4. National Diabetes Foot Care Audit Fourth Annual Report; 2019 https://files.digital.nhs.uk/FC/18ED7F/NDFA%204AR%20-%20Main%20Report%20v1.1.pdf

5. van Acker K. Diabetic Foot Disease: When the alarm to action is missing. International Diabetes Federation; 2015. https://www.diabetesresearchclinicalpractice.com/article/S0168-8227(15)00325-3/abstract

6. N Mottolini. Diabetes and lower limb complications. A thematic review of clinical negligence claims. NHS Resolution; 2022. https://resolution.nhs.uk/wp-content/uploads/2022/06/Diabetes_and_Lower_Limb_Complications.pdf

7. NIHR. Simple tool identifies the people with diabetes most likely to develop foot ulcers; 2022. https://evidence.nihr.ac.uk/alert/simple-tool-predicts-foot-ulcers-in-diabetes/

8. NICE [NG19]. Diabetic foot problems: prevention and management; Updated 2019 . https://www.nice.org.uk/guidance/ng19

9. Curtis L, Miller R. The 10-point training tool for staff education in inpatients diabetes. Journal of Diabetes Nursing; 2018. https://diabetesonthenet.com/journal-diabetes-nursing/10-point-training-tool-staff-education-inpatient-diabetes/

10. Diabetes UK. Testing for sensitivity in your feet. https://www.diabetes.org.uk/guide-to-diabetes/complications/feet/touch-the-toes

11. Royal College of Podiatry. Low risk of non-healing wounds and amputation. https://rcpod.org.uk/patient-information/diabetes/diabetes-leaflets/low-risk-of-non-healing-wounds-and-amputation

Richard Leigh
DPodM, BSc, MRCPod, FRCPodM, FFPM RCPS (Glasg)
Consultant Podiatrist,
Royal Free London NHS Foundation Trust
Council Member,
The Royal College of Podiatry
Chair, English Diabetes Footcare Network
Member of the London Clinical Senate Council
Visiting Professor Perm State Medical University
Practice Nurse 2024;54(4):16-19