The Importance of Annual Feet Examination in Diabetic Care


By Dr. Miriam Rotman

65,700 people with diabetes in the United States underwent one or more lower-extremity amputations in 2006, accounting to more than 60% of non-traumatic amputation in the country.

Diabetes is the leading cause of amputation of the lower limbs. It is clear that though as many as 50% of these amputations might be prevented through simple but effective foot care practices, patients (and their health care providers) are not doing enough to avoid amputations and the tremendous human and economic costs that this brings upon the patients. In the analysis of nearly 7,500 patients, presented at the (ADA) 63rd Scientific Sessions, both primary care physicians and endocrinologists failed to diagnose non-severe neuropathy in about 2/3 of cases. When it comes to severe neuropathy, about 1/4 endocrinologists and 1/3 primary care physicians miss the diagnosis.

People who have diabetes are vulnerable to nerve and vascular damage that can result in loss of protective sensation in the feet, poor circulation, and poor healing of foot ulcers. All of these conditions contribute to the high amputation rate in people with diabetes. The absence of nerve and vascular symptoms, however, does not mean that a patient’s feet are not at risk.

Risk of ulceration cannot be assessed without careful physical and neurological examination of the patient’s bare feet. Most physicians are not aware of the importance in asking the patient about neurological signs and symptoms — such as burning, tingling, numbness which all indicate neurological damage. The Semmes-Weinstein monofilament identified persons at increased risk of foot ulceration with a sensitivity of 66%-91% and a specificity of only 34%- 86%. The patient’s health-care providers suspected neuropathy when the patient was complaining of pain, burning and tingling but missed the diagnosis in most cases when the patient was suffering from numbness (lack of sensation).

Nerve conduction studies are generally considered the criterion standard for diagnosing peripheral neuropathy with a high degree of sensitivity (>85%) and specificity (85%-95%) and are optimal when used to evaluate diabetic patients with signs(pain, burning, numbness) and symptoms (loss of sensation, hypersensitivity, motor abnormalities) of neurological damage that might be suffering from other clinical diagnoses.

Good foot care, therefore, is an essential part of diabetes management — for patients as well as for health care providers, but unfortunately it is often overlooked.

A study of provider practices (below) found that clinicians were highly likely to prescribe preventive foot care behaviors when they were aware of a patient’s high risk for limb amputation as evidenced by prior history of foot ulcer. Clinician awareness of two other major risk factors (peripheral neuropathy or peripheral vascular disease), however, did not increase preventive care practices. The study’s authors concluded that physicians and patients need periodic reminders to identify patients in all high risk categories for ulcer or amputation as well as recognize the high risk group defined by moderate-severe peripheral neuropathy.

The key elements of preventive care include:

  • Annual examination of the feet by health care providers and referral for NCV when appropriate
  • Subsequent examination of high risk feet at each patient visit
  • Patient education
  • Careful glucose management

Based upon — “A Health Care Provider’s Guide to Preventing Diabetes Foot Problems” Published jointly by the National Institute of Diabetes and Digestive and Kidney Diseases and the US Dept. of HHS, November 2000