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In your exam of the extremities, check for leg swelling (pretibial or pedal edema). Check pulses on both the upper and lower extremities.

One of the macrovascular complications of diabetes is peripheral vascular disease, the result of which is diminished pulses in the extremities, especially the lower extremities. Patients with this condition complain of “claudication”, which is leg pain that occurs with exertion. Classically, this leg pain occurs reliably at a given distance (for instance, the patient will tell you his legs always begin to hurt after he has walked two blocks).

Other findings on physical exam that should raise concern for peripheral vascular disease include erythematous or cyanotic skin on the feet and lower legs, particularly if it shows pallor on elevation. There is often an absence of hair growth. The skin can be cool, thin, and shiny, in some cases with evidence that it has been injured with minimal trauma.

In the presence of peripheral vascular disease, any injury can heal more slowly, leading to ulceration and finally gangrene—a problem made much worse by concomitant neuropathy that prevents the patient from being aware of these changes. Presence of neuropathy can be identified by a number of means but failing the “monofilament test” means that the individual has enough neuropathy that they should be taking special precautions against injuries with protective shoes and avoiding going barefoot. The monofilament test will be demonstrated to you at the clinic.

Other features suggestive of neuropathy is the presence of plantar calluses or “cock-up toes”. With neuropathy, the foot loses its normal contour, the toes are drawn up resulting in greater pressure on the metatarsal heads with callus formation. These calluses are not only suggestive of neuropathy but also may be the place where an ulceration can first occur even without trauma. These individuals should be consistently wearing shoes with padded soles to avoid trauma from walking (e.g., diabetic shoes or very good walking shoes), and often benefit from an insole.

You also want to examine to foot for any signs of redness or blisters suggesting their shoes aren’t fitting right. Look at how they are or are not trimming their nails to make sure they aren’t performing “bathroom surgery” and not contributing to future ingrown toenails by trimming them too closely.

As mentioned previously, look for whether their skin is excessively dry suggesting they aren’t moisturizing enough. This can lead to cracking, another cause of infection that can lead to amputation. It is estimated that 50% of amputations can be prevented through these simple measures alone:

1. Educating the patient to avoid injuries by wearing good shoes, not going barefoot, or wearing open toed sandals;
2. Recommending daily foot inspections by the patient themselves so they can report any problems or redness early;
3. Daily or regular moisturization of the feet if they are dry; and
4. Health provider education at the time of examination to demonstrate how important foot care is and spot problems early.

Thus, as you move to examine the lower legs and feet, ask the patient about symptoms of claudication and pay attention to the appearance of the skin hair and nails. The exam of the feet is one of the most critical elements of your work at the GOODLIFE clinic.  Obviously, this exam cannot be performed if the patient is wearing shoes or socks.

For additional information and to view a video on the foot exam, click here for the Lower Extremity Amputation Prevention (LEAP) web site.