The Diabetic Foot Risk Stratification and Triage chart below has been developed by the Scottish Diabetes Foot Action Group and is included in the SIGN 116 guidelines. Following the foot screening process the individual should be assigned and informed of their risk category and a treatment and management plan introduced according to the chart if required.
There are 5 points tested with the monofilament on each foot:
- Apex 1st toe
- Apex 3rd toe
- 1st Metatarsal head
- 3rd 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.
- Lose of protective sensation resulting in the inability to feel pain
- 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 an individual is suffering from DPN is to test them with a 10g monofilament.
First show the individual that the monofilament is not sharp by performing the test on the back of your hand and then on the individual’s forearm. The next stage is to inform the individual that you will be testing each foot with their eyes closed and they have to say yes each time they feel the monofilament touch their foot.
There are 5 areas tested on each foot. They are the apex of the 1st and 3rd toes, the 1st, 3rd and 5th metatarsal heads. These tests are carried out in a random fashion with the monofilament at a 90° angle to the foot. The monofilament showed be depressed with enough force to cause a bend in the monofilament and should be in contact with the skin for between 1 and 2 seconds. The monofilament should not be allowed to slide across the surface of the skin and areas of callus or any breaks in the skin should be avoided.
- If the individual can not feel more than 8/10 of the tested sites then they can be diagnosed as having PDN and this can put them at risk of developing a diabetic foot ulcer. Any such individual need to be in a managed treatment plan. All individuals identified as Moderate risk should receive an annual assessment by a podiatrist which should include screening and the checking of individuals risk status. This should then lead to the introduction or review of a treatment /management plan, including reinforcement of education, formulated in consultation with the individual and tailored to suit the individual’s needs.
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 individual’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 individual 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
- Inability to maintain personal hygiene
- Inability to check feet for any problems
- Learning difficulties
Other risk factors
Any other risk factor which is not listed above can be placed in the text box in the SCI-Diabetes form.