Category: The Procedure (NHS England)

The Diabetic Foot Risk Stratification and Triage chart below has been developed from the NICE guideline [NG19]: Diabetic foot problems: prevention and management, using a format taken from the SIGN 116 guidelines. Following the foot screening process the patient should be assigned and informed of their risk category and a treatment and management plan introduced according to the chart if required.

Select the crosses on the image below for more details.

Download PDF for printing

• Risk stratification and triage chart (traffic lights) [.pdf, 434 KB]

There are 3 points tested with the monofilament on each foot:

• Plantar surface of the distal hallux
• 1st Metatarsal head
• 5th Metatarsal head

When performing the monofilament test the filament must be held at a 90° angle to the foot. Contact with the skin should last approximately between 1 and 2 seconds.

Try this out using the interactive simulation below.

Performing the monofilament test

Testing for diabetic neuropathy using a monofilament

Duration: 16 seconds, format: MP4

Demonstrating the monofilament test

Duration: 16 seconds, format: MP4

Some people with diabetes lose their perception of feeling in their feet. This is called Diabetic Peripheral Neuropathy (DPN) and is defined as

“the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes” (Bolton 1998).

Many people will be unaware that any such problems exist and up to 50 % of people at diagnosis may present with some signs of neurological changes.

DPN can lead to various problems.

1. Lose of protective sensation resulting in the inability to feel pain
2. Change of shape of the foot such as clawing of the toes resulting in areas of increased pressure which may cause areas of callus especially under the metatarsal heads.

The simplest and most evidence based way to determine if a patient is suffering from DPN is to test them with a 10g monofilament.

• Sensory examination should be carried out in a quiet and relaxed setting. First apply the monofilament on the patient’s hands (or elbow or forehead) so that he or she knows what to expect.
• The patient must not be able to see whether or where the examiner applies the monofilament. There are three sites to be tested on both feet are indicated. The 1st and 5th metatarsal heads and the plantar surface of the distal hallux.
• Apply the monofilament perpendicular to the skin surface.
• Apply sufficient force to cause the filament to bend or buckle.
• The total duration of the approach – skin contact and removal of the filament – should be approximately 2 seconds.
• Apply the filament along the perimeter of, not on, an ulcer site, callus, scar or necrotic tissue.
• Do not allow the filament to slide across the skin or make repetitive contact at the test site.
• Press the filament to the skin and ask the patient whether they feel the pressure applied (‘yes’/’no’) and next where they feel the pressure (‘left foot’/’right foot’).
• Repeat this application twice at the same site, but alternate this with at least one ‘mock’ application in which no filament is applied (total three questions per site).
• Protective sensation is present at each site if the patient correctly answers two out of three applications.
• Protective sensation is absent with two out of three incorrect answers – the patient is then considered to be at risk of ulceration.
• Encourage the patients during testing by giving positive feedback.
• The healthcare provider should be aware of the possible loss of buckling force of the monofilament if used for too long a period of time.

(Taken from the prevention and management of foot problems in diabetes: a summary guidance for daily practice 2015, based on the IWGDF Guidance documents)

Can you locate the posterior tibial pulse?

Can you locate the dorsalis pedis?

Diabetes is a condition that can affect the vascular system. The screening of somebody’s feet for signs of vascular insufficiency is a simple process and is carried out by palpating the two main pulses in the foot the dorsalis pedis and posterior tibial. If you can palpate either of these pulses on each foot then it is deemed the foot is sufficiently perfused vascularly and no further action needs to be taken apart from recording this. Some patient’s pulses are not easy to palpate even although their circulation is intact and this may be due to many factors i.e. the presence of swelling (oedema) or the fact that in up to 10% of the population the dorsalis pedis is not palpable. If the pulses are not palpable then the patient will need to have a more in depth vascular assessment to determine if there is a problem with their circulation. This assessment would generally be carried out by a specialist podiatrist who would take any appropriate action required.

The inability for somebody to self care or have help to self care can increase the risk of them developing a foot problem. The following factors may contribute to this situation:

• Visual impairment
• Arthritis
• Inability to maintain personal hygiene
• Inability to check feet for any problems
• Learning difficulties