Diabetic Foot Examination
A 12-step diabetic foot examination covering inspection, palpation, protective sensation, vascular assessment and risk stratification.
Endocrinology · Self-paced
12 sections · 63 actionable steps
Before you begin
Equipment
10 g (5.07) Semmes-Weinstein monofilament
128 Hz tuning fork
Neurotip and tendon hammer
Hand-held Doppler and BP cuff for ABI / TBI
Gloves, good lighting, a mirror for self-care teaching
The aim
Find the foot at risk before it ulcerates.
Every finding feeds one question: does this person have loss of protective sensation, peripheral artery disease, deformity or active foot disease?
How to use this guide
Read it through: Learn the sequence and the reason behind each step before you practise.
Practise in pairs: One examines, one reads the steps aloud and ticks each circle as it is completed.
Present aloud: Finish every attempt with a summary and a risk category, as you would for an examiner.
The sequence
Talk
Introduce, consent, risk history
Look
Shoes, skin, nails, shape
Feel
Temperature, refill, pulses
Test
Sensation, joints, vascular
Stratify
Risk category and plan
Step 1. Introduction
Hand hygiene
Hand wash/rub before patient contact
Introduce yourself
Name and role; confirm the patient's name and date of birth
Explain the purpose
“I'd like to check your feet for nerve, circulation and skin changes that diabetes can cause.”
Obtain consent
Ask about pain in the legs or feet before you start
Position and exposure
Reclined at about 45°, legs exposed to the knees, shoes and socks off both feet
Offer a chaperone
As per local policy
Why both feet?
Comparison is your most useful tool. Temperature, colour, pulses and sensation are all interpreted side to side.
Step 2. Focused Foot-Risk History
Diabetes
Type, duration and recent glycaemic control (HbA1c)
Previous foot disease
Ulcer, amputation, Charcot foot or foot surgery — the strongest predictors of a new ulcer
Neuropathic symptoms
Numbness, tingling, burning or shooting pain, often worse at night
Vascular symptoms
Calf claudication, rest pain, cold feet, slow-healing wounds
Comorbidities
End-stage kidney disease or dialysis, retinopathy (can they see their feet?), smoking
Self-care
Who checks their feet, podiatry input, footwear and barefoot walking
History in one breath
“Have you ever had an ulcer or an amputation? Any numbness, burning or pins and needles? Any pain in your calves when you walk?”
Remember
Patients with neuropathy often have no symptoms. A negative history does not exclude loss of protective sensation.
Step 3. General Inspection
Around the bed
Walking aids, offloading boots or orthotics, wheelchair, dressings
Patient
Comfort, body habitus, mobility, visual impairment
Hands
Finger-prick marks; cheiroarthropathy (positive prayer sign)
Legs
Muscle wasting, oedema, scars from vein harvest or bypass grafts
Step 4. Footwear and Socks
Shoe type and fit
Correct length, width and depth; secure fastening; not too tight
Wear pattern
Uneven wear suggests abnormal loading or gait
Inside the shoe
Feel for foreign bodies, prominent seams or worn insoles
Socks
Blood or exudate staining; tight elastic bands
Commonly missed
Heels — lift each foot. Between every toe. Inside both shoes. Old amputation sites.
Say it aloud
“I'm looking at the dorsum, the sole, the heel and between the toes of each foot.”
Step 5. Skin and Nails
Colour
Pallor, rubor, cyanosis or mottling (ischaemia); erythema (infection)
Trophic changes
Hair loss, thin shiny skin (peripheral artery disease)
Dryness and fissures
Anhidrosis from autonomic neuropathy; heel fissures
Callus and corns
Over metatarsal heads, toe tips and heels
Pre-ulcerative signs
Blisters, haemorrhage within callus, fissures
Between the toes
Gently separate each toe: maceration, tinea pedis, interdigital ulcers
Nails
Onychomycosis, thickening, ingrown or poorly cut nails, subungual haemorrhage
Ulcers and gangrene
Site, size, depth, base, edge, surrounding skin, exudate, odour; dry or wet gangrene
An ulcer in waiting
Haemorrhage within callus, blisters and fissures are pre-ulcerative. They need prompt podiatry care and offloading.
Callus tells a story
Callus marks where the foot is overloaded. Under a metatarsal head in a neuropathic foot, it is a classic site for an ulcer to form.
Describing an ulcer
Say each in turn.
| Sequence | What to describe |
|---|---|
| 01 · Site | Forefoot, midfoot or hindfoot; plantar, dorsal, interdigital |
| 02 · Size | Length × width in mm |
| 03 · Depth | Superficial, to tendon, or probes to bone |
| 04 · Base | Granulating, sloughy or necrotic |
| 05 · Edge | Punched out, callused, undermined |
| 06 · Surrounds | Erythema, warmth, swelling, maceration |
| 07 · Exudate | Amount, colour, odour |
| 08 · Perfusion | Pulses and Doppler in that foot |
Step 6. Foot Shape and Deformity
Toe deformities
Claw and hammer toes, hallux valgus (bunion)
Arch and forefoot
Pes cavus, prominent metatarsal heads, fat pad atrophy
Charcot changes
Midfoot collapse, rocker-bottom deformity
Previous amputation
Toe, ray or transmetatarsal; check the stump and transfer lesions
Swelling
Unilateral (infection, Charcot, DVT) versus bilateral oedema
Finding the pulses
Dorsalis pedis — ask the patient to lift the big toe to show the EHL tendon; feel just lateral to it.
Posterior tibial — halfway between the medial malleolus and the Achilles tendon.
Hot, swollen foot
A unilateral warm, swollen foot (often more than 2 °C warmer) in someone with neuropathy is active Charcot until proven otherwise.
Bedside record
Educational reference table — compare right and left findings during practice; do not enter patient information.
| Finding | Right | Left |
|---|---|---|
| Dorsalis pedis | ||
| Posterior tibial | ||
| Capillary refill | ||
| Temperature | ||
| Monofilament (sites felt / 3) | ||
| Vibration (level felt) | ||
| Ankle reflex |
Step 7. Palpation and Pulses
Temperature
Back of hand, toes to shin, compare sides; a cool foot suggests ischaemia, a warm, swollen foot on one side suggests infection or Charcot
Capillary refill
Press the pulp of the hallux for 5 s; normal is under 2 s
Dorsalis pedis
Dorsum of foot, just lateral to the extensor hallucis longus tendon
Posterior tibial
Behind and below the medial malleolus
Popliteal
Knee slightly flexed, both hands, fingertips in the popliteal fossa
Oedema and tenderness
Pitting over the shin; tenderness or crepitus over any wound
Step 8. Monofilament Testing
Demonstrate
Apply to the hand, elbow or forehead so the patient knows what to expect
Eyes closed
The patient must not see whether or where you apply it
Technique
Perpendicular to the skin, enough force to bend the filament, about 2 s in total
Choose the sites
Three sites on each foot; never over ulcer, callus, scar or necrotic tissue
Ask “yes or no” and “where”
Apply twice at each site, alternating with at least one sham (three questions per site)
Interpret
Present if 2 of 3 answers are correct; absent if 2 of 3 are incorrect (loss of protective sensation)
Monofilament sites · plantar view
Four labelled sites are shown on each sole: 1 hallux, 2 first metatarsal head, 3 third metatarsal head and 4 fifth metatarsal head. Test three sites on each foot, commonly 1, 2 and 4. Move to nearby intact skin if a site has callus or an ulcer.
- 1 · hallux
- 2 · first metatarsal head
- 3 · third metatarsal head
- 4 · fifth metatarsal head
Monofilament technique
About 2 seconds in total: approach perpendicular to the skin; press until the filament buckles and hold about 1 second; lift off cleanly without sliding or repeating taps; ask “Can you feel it?” and “Where?” Apply twice per site, plus one sham.
Step 9. Other Sensory Tests and Reflexes
Vibration – 128 Hz tuning fork
Demonstrate on the wrist; apply to the dorsal distal phalanx of the hallux, twice plus one sham. If absent, move proximally: malleolus, then tibial tuberosity
Proprioception
Hold the hallux by its sides; demonstrate up and down, then test with eyes closed
Pinprick or light touch
Work distal to proximal to map a stocking distribution
Ankle reflexes
Use reinforcement (Jendrassik manoeuvre) if absent
Ipswich Touch Test
If no equipment: touch the tips of toes 1, 3 and 5 for 1–2 s; loss of protective sensation is likely if 2 or more sites are not felt
Ipswich Touch Test
If no equipment: touch the tips of toes 1, 3 and 5 for 1–2 s; loss of protective sensation is likely if 2 or more sites are not felt.
Step 10. Joint Mobility and Gait
First MTP joint
Passive dorsiflexion; hallux limitus raises forefoot plantar pressure
Ankle and subtalar joints
Passive range; limited joint mobility increases forefoot loading
Gait
If safe: heel strike, toe-off, foot slap, unsteadiness
Romberg's test
Positive suggests sensory ataxia from large-fibre neuropathy
ABI in diabetes
Medial arterial calcification can make the ABI falsely normal or high. Check Doppler waveforms and toe pressures too.
PAD is less likely if
Triphasic or biphasic waveforms; ABI 0.9–1.3; TBI 0.70 or above.
Step 11. Bedside Vascular Tests
Buerger's test
Elevate the legs: pallor below 20° suggests severe ischaemia; then dangle over the bed edge and watch for dependent rubor
Hand-held Doppler
Pedal waveforms: triphasic or biphasic reassuring; monophasic suggests PAD
Ankle-brachial index
Highest ankle systolic pressure ÷ highest brachial systolic pressure
Toe pressure and TBI
Use when arteries are calcified (ABI above 1.3); TBI below 0.70 is abnormal
In a timed station
If you are not asked to perform them, offer Buerger's test, Doppler and ABI/TBI, and say what you would look for.
Step 12. Conclusion
Thank and redress
Help with socks and shoes; make sure the patient is comfortable
Hand hygiene
Hand rub/hand wash
Summarise and stratify
Present key findings and state the IWGDF risk category
Further assessment
Full lower-limb neuro and vascular exam; BGL, HbA1c, lipids, eGFR, urine ACR; ABI/TBI; X-ray ± MRI if ulcer or suspected osteomyelitis or Charcot
Plan and educate
Daily self-inspection, never walk barefoot, moisturise (not between toes), nail care, footwear, podiatry or high-risk foot service
Run it from memory
Cover the steps and recite the sequence.
- Step 1. Introduction
- Step 2. Focused Foot-Risk History
- Step 3. General Inspection
- Step 4. Footwear and Socks
- Step 5. Skin and Nails
- Step 6. Foot Shape and Deformity
- Step 7. Palpation and Pulses
- Step 8. Monofilament Testing
- Step 9. Other Sensory Tests and Reflexes
- Step 10. Joint Mobility and Gait
- Step 11. Bedside Vascular Tests
- Step 12. Conclusion
What your findings mean
IWGDF 2023 risk stratification
Adopted by the 2021 Australian guidelines.
LOPS = loss of protective sensation; PAD = peripheral artery disease. People at moderate or high risk should be reviewed by a podiatrist or high-risk foot service. Screening intervals are expert opinion.
| Category | Risk | Characteristics | Foot screening |
|---|---|---|---|
| 0 | Very low | No LOPS and no signs of PAD | Once a year |
| 1 | Low | LOPS or PAD | Every 6–12 months |
| 2 | Moderate | LOPS + PAD, LOPS + deformity, or PAD + deformity | Every 3–6 months |
| 3 | High | LOPS or PAD plus previous ulcer, lower-limb amputation or end-stage kidney disease | Every 1–3 months |
Neuropathic vs ischaemic ulcer
Mixed neuro-ischaemic ulcers are common. Assess perfusion in every ulcer.
| Finding | Neuropathic | Ischaemic |
|---|---|---|
| Site | Pressure points: metatarsal heads, toe tips, heel | Toe tips, foot margins, between toes |
| Wound | Punched out, rimmed by callus, pink base | Pale or necrotic base, irregular edge |
| Pain | Painless | Often painful |
| Foot | Warm, dry, pulses present | Cool, pale, hairless, pulses absent |
Active foot disease — refer urgently
Foot ulcer — any full-thickness skin break.
Infection — spreading erythema, warmth, pus; systemic signs are an emergency.
Suspected Charcot — hot, red, swollen foot; offload while awaiting review.
Limb-threatening ischaemia — rest pain, gangrene, non-healing wound with PAD.
Probe-to-bone positive — think osteomyelitis.
Ankle-brachial index
A TBI below 0.70 is abnormal and is more reliable than ABI when arteries are calcified, which is common in diabetes and kidney disease.
| < 0.5 | 0.5–0.9 | 0.9–1.3 | > 1.3 |
|---|---|---|---|
| Severe PAD | PAD | Normal range | Non-compressible |
In a person with an ulcer
IWGDF suggests urgent vascular imaging and consideration of revascularisation if any of these are present:
| Ankle pressure | ABI | Toe pressure |
|---|---|---|
| < 50 mmHg | < 0.5 | < 30 mmHg |
Presenting your findings
Model presentation
“I examined the feet of Mr Taylor, a 64-year-old man with type 2 diabetes. There was callus with haemorrhage under the right first metatarsal head and bilateral claw toes, with dry skin but no ulceration. Both feet were warm, capillary refill was under 2 seconds and pedal pulses were palpable bilaterally. Protective sensation was absent at all three sites on both feet with a 10 g monofilament, and vibration sense was absent to the medial malleoli.
These findings indicate loss of protective sensation with foot deformity and a pre-ulcerative lesion — IWGDF risk category 2. I would complete my assessment with Doppler waveforms and ABI/TBI, and arrange prompt podiatry review for the callus, footwear advice and 3–6-monthly foot screening.”
Structure
01 Who — Name, age, diabetes type
02 Look — Skin, nails, deformity, ulcers
03 Feel — Temperature, capillary refill, pulses
04 Test — Monofilament, vibration, reflexes
05 Conclude — Risk category, investigations, plan
Common pitfalls
Skipping heels, between the toes and the shoes
Testing over callus, or sliding the monofilament
No sham applications, so a “yes” can't be trusted
Not comparing sides
Assuming a normal ABI excludes PAD
Finishing without a risk category and plan
Key education messages
Check both feet every day, using a mirror or a carer.
Wash daily and dry well between the toes.
Moisturise, but not between the toes.
Never walk barefoot, indoors or out.
Check inside shoes before putting them on.
Seek help the same day for any wound, redness or swelling.
Sources
Schaper NC et al. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). International Working Group on the Diabetic Foot, 2023.
Diabetes Feet Australia. 2021 Australian evidence-based guidelines for diabetes-related foot disease. Australian Diabetes Society, 2021.
RACGP. Management of type 2 diabetes: diabetes-related foot care.
Always follow your own medical school's marking criteria and local clinical policies.
Educational use only
Made for learning, not for clinical decision-making.
Educational only. Not medical advice or a substitute for supervised clinical training.
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