Comprehensive Foot Examination and Risk Assessment
A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists
- Andrew J.M. Boulton, MD, FRCP1,2,
- David G. Armstrong, DPM, PHD3,
- Stephen F. Albert, DPM, CPED4,
- Robert G. Frykberg, DPM, MPH5,
- Richard Hellman, MD, FACP6,7,
- M. Sue Kirkman, MD8,
- Lawrence A. Lavery, DPM, MPH9,
- Joseph W. LeMaster, MD, MPH10,
- Joseph L. Mills, Sr., MD11,
- Michael J. Mueller, PT, PHD12,
- Peter Sheehan, MD13 and
- Dane K. Wukich, MD14
- 1Manchester Diabetes Centre, Manchester, U.K
- 2Division of Endocrinology, Diabetes & Metabolism, University of Miami School of Medicine, Miami, Florida
- 3Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
- 4Denver Department of Veterans Affairs Medical Center, Denver, Colorado
- 5Carl T. Hayden VA Medical Center, Phoenix, Arizona
- 6American Association of Clinical Endocrinologists, Jacksonville, Florida
- 7Department of Medicine, University of Missouri–Kansas City School of Medicine, Kansas City, Missouri
- 8American Diabetes Association, Alexandria, Virginia
- 9Department of Surgery, Texas A&M Health Science Center, Temple, Texas
- 10Department of Family & Community Medicine, University of Missouri–Columbia School of Medicine, Columbia, Missouri
- 11Department of Surgery, University of Arizona Health Sciences Center, Tucson, Arizona
- 12Program in Physical Therapy and Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
- 13Department of Medicine, Mount Sinai School of Medicine, New York, New York
- 14Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Corresponding author: Andrew J.M. Boulton, aboulton{at}med.miami.edu
It is now 10 years since the last technical review on preventative foot care was published (1), which was followed by an American Diabetes Association (ADA) position statement on preventive foot care in diabetes (2). Many studies have been published proposing a range of tests that might usefully identify patients at risk of foot ulceration, creating confusion among practitioners as to which screening tests should be adopted in clinical practice. A task force was therefore assembled by the ADA to address and concisely summarize recent literature in this area and then recommend what should be included in the comprehensive foot exam for adult patients with diabetes. The committee was cochaired by the immediate past and current chairs of the ADA Foot Care Interest Group (A.J.M.B. and D.G.A.), with other panel members representing primary care, orthopedic and vascular surgery, physical therapy, podiatric medicine and surgery, and the American Association of Clinical Endocrinologists.
THE PATHWAY TO FOOT ULCERATION
The lifetime risk of a person with diabetes developing a foot ulcer may be as high as 25%, whereas the annual incidence of foot ulcers is ∼2% (3–7). Up to 50% of older patients with type 2 diabetes have one or more risk factors for foot ulceration (3,6). A number of component causes, most importantly peripheral neuropathy, interact to complete the causal pathway to foot ulceration (1,3–5). A list of the principal contributory factors that might result in foot ulcer development is provided in Table 1.
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Risk factors for foot ulcers
The most common triad of causes that interact and ultimately result in ulceration has been identified as neuropathy, deformity, and trauma (5). As identification of those patients at risk of foot problems is the first step in preventing such complications, this report will focus on key components of the …
