Clinical Examination and Risk Classification of the Diabetic Foot

Foot ulceration is one of the most common precursors to lower extremity amputations among persons with diabetes (Singh et al., JAMA. 2005; 293(2):217–28; Boulton and Vileikyte, Wounds. 2000; 12(Suppl B):12B–8; Reiber et al., Rehabil Res Dev. 2001; 38(3):309–17). Ulcerations are pivotal events in limb loss for two important reasons. They allow an avenue for infection (Armstrong and Lipsky, Diabetes Technol Ther. 2004; 6:167–77), 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 (Armstrong and Lipsky, Diabetes Technol Ther. 2004; 6:167–77). Foot ulcers, therefore, play a central role in the causal pathway to lower extremity amputation (Pecoraro et al., Diabetes Care. 1990; 13:513–21).

[1]  M. Goldner.  The Fate of the Second Leg in the Diabetic Amputee , 1960, Diabetes.

[2]  M. Ellenberg,et al.  Diabetes mellitus: theory and practice , 1970 .

[3]  J. Bagdade,et al.  Impaired Leukocyte Function in Patients with Poorly Controlled Diabetes , 1974, Diabetes.

[4]  J. Phair,et al.  Neutrophil dysfunction in diabetes mellitus. , 1975, The Journal of laboratory and clinical medicine.

[5]  Wilson Wr,et al.  Leukocyte chemotaxis in diabetic patients and their nondiabetic first-degree relatives. , 1976 .

[6]  Wagner Fw.  The Dysvascular Foot: A System for Diagnosis and Treatment: , 1981 .

[7]  D. Lezotte,et al.  Limited joint mobility in diabetes mellitus of childhood: natural history and relationship to growth impairment. , 1982, The Journal of pediatrics.

[8]  C. I. Franks,et al.  The Measurement of Pressures under the Foot , 1982, Foot & ankle.

[9]  A. Rosenbloom.  Skeletal and joint manifestations of childhood diabetes. , 1984, Pediatric clinics of North America.

[10]  Wound assessment in clinical practice. A critical review of methods and their application. , 2009, Acta medica Scandinavica. Supplementum.

[11]  F. Logerfo,et al.  Current concepts. Vascular and microvascular disease of the foot in diabetes. Implications for foot care. , 1984, The New England journal of medicine.

[12]  D. Knighton,et al.  Classification and treatment of chronic nonhealing wounds. Successful treatment with autologous platelet-derived wound healing factors (PDWHF). , 1986, Annals of surgery.

[13]  M. Cornwall,et al.  Relationship between Hallux Limitus and Ulceration of the Great Toe. , 1988, The Journal of orthopaedic and sports physical therapy.

[14]  J. Calhoun,et al.  Treatment of Diabetic Foot Infections: Wagner Classification, Therapy, and Outcome , 1988, Foot & ankle.

[15]  C. Agardh,et al.  Prognostic Value of Systolic Ankle and Toe Blood Pressure Levels in Outcome of Diabetic Foot Ulcer , 1989, Diabetes Care.

[16]  C. Thivolet,et al.  Measuring Vibration Sensations With Graduated Tuning Fork: Simple and Reliable Means to Detect Diabetic Patients at Risk of Neuropathic Foot Ulceration , 1990, Diabetes Care.

[17]  J. Assal,et al.  The Tuning Fork Revisited , 1990, Diabetic medicine : a journal of the British Diabetic Association.

[18]  G. Reiber,et al.  Pathways to Diabetic Limb Amputation: Basis for Prevention , 1990, Diabetes Care.

[19]  D. Bild,et al.  Comparison of Quantitative Sensory-Threshold Measures for Their Association With Foot Ulceration in Diabetic Patients , 1990, Diabetes Care.

[20]  A. Veves,et al.  Relationship of Limited Joint Mobility to Abnormal Foot Pressures and Diabetic Foot Ulceration , 1991, Diabetes Care.

[21]  P. Helm,et al.  Recurrence of neuropathic ulceration following healing in a total contact cast. , 1991, Archives of physical medicine and rehabilitation.

[22]  A. Novick,et al.  Methods of treating plantar ulcers. , 1991, Physical therapy.

[23]  J. Bacharach,et al.  Predictive value of transcutaneous oxygen pressure and amputation success by use of supine and elevation measurements. , 1992, Journal of vascular surgery.

[24]  S. Rith-Najarian,et al.  Identifying Diabetic Patients at High Risk for Lower-Extremity Amputation in a Primary Health Care Setting: A prospective evaluation of simple screening criteria , 1992, Diabetes Care.

[25]  T. Koepsell,et al.  Risk Factors for Amputation in Patients with Diabetes Mellitus , 1992, Annals of Internal Medicine.

[26]  A. Novick,et al.  Healing rates of plantar ulcers in leprosy and diabetes. , 1992, Leprosy review.

[27]  T. Orchard,et al.  Assessment of Peripheral Vascular Disease in Diabetes Report and Recommendations of an International Workshop* Sponsored by the American Diabetes Association and the American Heart Association September 18‐20, 1992 New Orleans, Louisiana , 1993, Circulation.

[28]  Elective foot surgery in limbs with arterial disease. , 1993, Clinical orthopaedics and related research.

[29]  D. Strandness,et al.  Assessment of peripheral vascular disease in diabetes. Report and recommendations of an international workshop sponsored by the American Heart Association and the American Diabetes Association 18-20 September 1992, New Orleans, Louisiana. , 1993, Diabetes care.

[30]  R. Macfarlane,et al.  The Description and Classification of Diabetic Foot Lesions , 1993 .

[31]  A. Veves,et al.  The Prediction of Diabetic Neuropathic Foot Ulceration Using Vibration Perception Thresholds: A prospective study , 1994, Diabetes Care.

[32]  L. Lavery,et al.  Increased Foot Pressures After Great Toe Amputation in Diabetes , 1995, Diabetes Care.

[33]  L. Uccioli,et al.  Manufactured Shoes in the Prevention of Diabetic Foot Ulcers , 1995, Diabetes Care.

[34]  G. Gibbons,et al.  Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients. , 1995, JAMA.

[35]  J. Birke,et al.  First Ray Joint Limitation, Pressure, and Ulceration of the First Metatarsal Head in Diabetes Mellitus , 1995, Foot & ankle international.

[36]  W. F. Todd,et al.  1995 William J. Stickel Bronze Award. Prevalence of mixed infections in the diabetic pedal wound. A retrospective review of 112 infections. , 1995, Journal of the American Podiatric Medical Association.

[37]  D. Nardone.  Probing to bone in infected pedal ulcers. , 1995, JAMA.

[38]  Michael J. Mueller,et al.  Identifying patients with diabetes mellitus who are at risk for lower-extremity complications: use of Semmes-Weinstein monofilaments. , 1996, Physical therapy.

[39]  D. Armstrong,et al.  Value of white blood cell count with differential in the acute diabetic foot infection. , 1996, Journal of the American Podiatric Medical Association (Print).

[40]  D. Armstrong,et al.  Puncture wounds: normal laboratory values in the face of severe infection in diabetics and non-diabetics. , 1996, The American journal of medicine.

[41]  D. Armstrong,et al.  Classification of diabetic foot wounds. , 1996, The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons.

[42]  T. Greene,et al.  A Foot Risk Classification System to Predict Diabetic Amputation in Pima Indians , 1996, Diabetes Care.

[43]  L. Lavery,et al.  Reducing Dynamic Foot Pressures in High-Risk Diabetic Subjects With Foot Ulcerations: A comparison of treatments , 1996, Diabetes Care.

[44]  D. Armstrong,et al.  Leukocytosis is a poor indicator of acute osteomyelitis of the foot in diabetes mellitus. , 1996, The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons.

[45]  P. Cavanagh,et al.  Biomechanical Aspects of Diabetic Foot Disease: Aetiology, Treatment, and Prevention , 1996, Diabetic medicine : a journal of the British Diabetic Association.

[46]  L. Lavery,et al.  The Development of Foot Deformities and Ulcers After Great Toe Amputation in Diabetes , 1996, Diabetes Care.

[47]  A. Boulton,et al.  The Tactile Circumferential Discriminator: A new, simple screening device to identify diabetic patients at risk of foot ulceration , 1997, Diabetes Care.

[48]  A. Vinik,et al.  Electron microscopic investigation of the effects of diabetes mellitus on the Achilles tendon. , 1997, The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons.

[49]  D. Murdoch,et al.  The natural history of great toe amputations. , 1997, The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons.

[50]  W. F. Todd,et al.  Infrared dermal thermometry for the high-risk diabetic foot. , 1997, Physical therapy.

[51]  David G Armstrong,et al.  Validation of a Diabetic Wound Classification System: The contribution of depth, infection, and ischemia to risk of amputation , 1998, Diabetes Care.

[52]  D. Armstrong,et al.  Practical criteria for screening patients at high risk for diabetic foot ulceration. , 1998, Archives of internal medicine.

[53]  D. Armstrong,et al.  Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration. , 1998, Archives of internal medicine.

[54]  A. Veves,et al.  Role of Neuropathy and High Foot Pressures in Diabetic Foot Ulceration , 1998, Diabetes Care.

[55]  A. Boulton,et al.  Multicenter Study of the Incidence of and Predictive Risk Factors for Diabetic Neuropathic Foot Ulceration , 1998, Diabetes Care.

[56]  K A Athanasiou,et al.  Is there a critical level of plantar foot pressure to identify patients at risk for neuropathic foot ulceration? , 1998, The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons.

[57]  R. Mazze,et al.  Reducing lower-extremity amputations due to diabetes. Application of the staged diabetes management approach in a primary care setting. , 1998, The Journal of family practice.

[58]  D. Armstrong,et al.  Who is at risk for diabetic foot ulceration? , 1998, Clinics in podiatric medicine and surgery.

[59]  D G Smith,et al.  Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. , 1999, Diabetes care.

[60]  D. Armstrong,et al.  Loss of protective sensation: a practical evidence-based definition. , 1999, The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons.

[61]  J. Mason,et al.  A systematic review of foot ulcer in patients with Type 2 diabetes mellitus. II: treatment , 1999, Diabetic medicine : a journal of the British Diabetic Association.

[62]  D G Smith,et al.  A prospective study of risk factors for diabetic foot ulcer. The Seattle Diabetic Foot Study. , 1999, Diabetes care.

[63]  D. Armstrong,et al.  Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. , 1999, The Journal of bone and joint surgery. American volume.

[64]  Paul Newrick,et al.  International Consensus on the Diabetic Foot , 2000, BMJ : British Medical Journal.

[65]  L A Lavery,et al.  Reliability of digital videometry and acetate tracing in measuring the surface area of cutaneous wounds. , 2000, Diabetes research and clinical practice.

[66]  D. Armstrong,et al.  Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial. , 2000, Diabetes care.

[67]  Andrew J.M. Boulton,et al.  The Foot in diabetes , 2000 .

[68]  J Booth,et al.  Differences in the performance of commercially available 10-g monofilaments. , 2000, Diabetes care.

[69]  O. Petrov,et al.  The durability of the Semmes-Weinstein 5.07 monofilament. , 2000, The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons.

[70]  The 10-g monofilament: the diagnostic divining rod for the diabetic foot? , 2000, Diabetes care.

[71]  D. Patrick,et al.  A comparison of diabetic foot ulcer patients managed in VHA and non-VHA settings. , 2001, Journal of rehabilitation research and development.

[72]  D. Armstrong,et al.  Classification of wounds of the diabetic foot , 2001, Current diabetes reports.

[73]  B. Perkins,et al.  Evaluation of three screening tests and a risk assessment model for diagnosing peripheral neuropathy in the diabetes clinic , 2001 .

[74]  L. Lavery,et al.  Effectiveness of the diabetic foot risk classification system of the International Working Group on the Diabetic Foot. , 2001, Diabetes care.

[75]  I Tarawneh,et al.  A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems. , 2001, Diabetes care.

[76]  [Examination of peripheral sensibility. Vibration test is more sensitive than monofilament test]. , 2002, Lakartidningen.

[77]  H Gin,et al.  Comparison between monofilament, tuning fork and vibration perception tests for screening patients at risk of foot complication. , 2002, Diabetes & metabolism.

[78]  Handbook of Lower Extremity Infections , 2002 .

[79]  J. Griffiths,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 , 2002, Diabetic medicine : a journal of the British Diabetic Association.

[80]  Robert G. Smith.  Validation of Wagner's classification: a literature review. , 2003, Ostomy/wound management.

[81]  P. Cavanagh,et al.  Foot problems in diabetes: an overview. , 2004, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[82]  N. Schaper,et al.  Diabetic foot ulcer classification system for research purposes: a progress report on criteria for including patients in research studies , 2004, Diabetes/Metabolism Research Reviews.

[83]  A. Veves,et al.  The risk of foot ulceration in diabetic patients with high foot pressure: a prospective study , 1992, Diabetologia.

[84]  D. Armstrong,et al.  Advances in the treatment of diabetic foot infections. , 2004, Diabetes technology & therapeutics.

[85]  S. Sauseng,et al.  The value of the Rydel‐Seiffer tuning fork as a predictor of diabetic polyneuropathy compared with a neurothesiometer , 2004, Diabetic medicine : a journal of the British Diabetic Association.

[86]  D. Armstrong,et al.  Preventing foot ulcers in patients with diabetes. , 2005, JAMA.

[87]  E. Etchells,et al.  Clinical examination for the detection of protective sensation in the feet of diabetic patients , 1999, Journal of General Internal Medicine.

[88]  D. Armstrong,et al.  Probe-to-Bone Test for Diagnosing Diabetic Foot Osteomyelitis , 2007, Diabetes Care.

[89]  A. Boulton,et al.  The diabetic foot. , 1988, Clinics in dermatology.

[90]  D. Murdoch,et al.  Reevaluating the Way We Classify the Diabetic Foot , 2008, Diabetes Care.

[91]  W. Caputo.  Surgical management of the diabetic foot. , 2008, Wounds : a compendium of clinical research and practice.

[92]  F. Logerfo,et al.  Vascular and Microvascular Disease of the Foot in Diabetes , 2010 .

[93]  E. Boyko,et al.  Risk stratification systems for diabetic foot ulcers: a systematic review , 2011, Diabetologia.

[94]  G. Rayman,et al.  The Ipswich Touch Test , 2011, Diabetes Care.

[95]  V. Turhan,et al.  Performance of the probe-to-bone test in a population suspected of having osteomyelitis of the foot in diabetes. , 2012, Journal of the American Podiatric Medical Association.

[96]  A. Boulton,et al.  A pocket‐sized disposable device for testing the integrity of sensation in the outpatient setting , 2012, Diabetic medicine : a journal of the British Diabetic Association.