Practical Guidelines - Addendum

Guidelines 

 

 

Sensory foot examination

Neuropathy can be detected using the 10g (5.07 Semmes-Weinstein) monofilament, tuning fork (128 Hz), and/or cotton wisp.

Semmes-Weinstein monofilament

  • Sensory examination should be done in a quiet and relaxed setting. First apply the monofilament on the patient's hands (or elbow, or forehead) so the patients know what to expect.
  • The patient must not be able to see if and where the examiner applies the filament. The three sites to be tested on both feet are indicated in figure 6.
  • Apply the monofilament perpendicular to the skin surface (figure 7a).
  • Apply sufficient force to cause the filament to bend or buckle (figure 7b).
  • 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 and 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 IF they feel the pressure applied (yes/no) and next WHERE they feel the pressure applied (left/right foot).
  • Repeat this application twice at the same site, but alternate this with at least one "sham" application, in which no filament is applied (total three questions per site).
  • Protective sensation is present at each site if the patients correctly answers two out of three applications. Protective sensation is absent with two out of three incorrect answers, and the patient is then considered to be at risk of ulceration.
  • Encourage the patients during testing.

 

Fig 6. Sites to be tested with the monofilaments

 

 

Fig 7a and 7b. Application of the monofilaments

 

Tuning fork

  • The sensory exam should be done in a quiet and relaxed setting. First apply the tuning fork on the patient's wrists (or elbow, or clavicula) so the patient knows what to expect.
  • The patient must not be able to see if and where the examiner applies the tuning fork. The tuning fork is applied on a bony part on the dorsal side of the distal phalanx of the first toe.
  • It should be applied perpendicularly with a constant pressure (figure 8).
  • Repeat this application twice, but alternate this with at least one "sham" application, in which the tuning fork is not vibrating.
  • The test is positive if the patient correctly answered at least two out of three applications, and negative ("at risk for ulceration") with two out of three incorrect answers.
  • If the patient is unable to sense the vibrations at the big toe, the test is repeated more proximally (malleolus, tibial tuberositas).
  • Encourage the patient during testing.

 

Fig 8. How to use a tuning fork

 

 

Easy to use foot screening assessment sheet for clinical examination

The foot is at risk if any of the below are present
Deformity or bony prominences
Yes/No
Skin not intact (ulcer)
Yes/No
Neuropathy
   - Monofilament undetectable
Yes/No
   - Tuning fork undetectable
Yes/No
   - Cotton wool undetectable
Yes/No
Abnormal pressure, callus
Yes/No
Loss of joint mobility
Yes/No
Foot pulses
   - Tibial posterior artery absent
Yes/No
   - Dorsal pedal artery absent
Yes/No
Discoloration on dependency
Yes/No
Any others
  - previous ulcer
Yes/No
  - amputation
Yes/No
Inappropriate footwear
Yes/No
 
Actions to be taken
Action recommended
Yes/No
Referral
Yes/No

 

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