In a busy private practice there may be little time to carry out a full diabetes assessment. Therefore, if you use the suggested tests below you can build up a risk profile for your patient.
10 gram Bailey Retractable Monofilament
Fully extend the monofilament.Demonstrate the monofilament test on the patients hand – they ought to know what it feels like, and that it won’t hurt. Test the hallux, then the 1st, 3rd and 5th metatarsophalangeal joints. This means you are testing all three plantar nerves.Do not test on callus or on broken skin. If the patient is unable to feel two or more test sites, class them as neuropathic .
Vibration Perception Threshold
Using a 128 Hertz tuning fork, hold the base of the fork and strike against your own hand, or pinch the ends of the fork together and release. Whilst the fork is vibrating, hold the flat base against the patients hand. Again, they’ll know what to expect and they know not to respond to the cold steel.
Place vibrating fork against bony prominences around great toe, 1st MTPjoint and 5th MTPjoint. If patient is unable to sense the vibration, make a note.
Temperature Differentiation
Using TipTherm®, place one end against the patients foot and hold for three seconds. Then test the other end of TipTherm®, near the same spot and ask the patient if they could sense one end was warmer than the other. Please bear in mind, most patients can become insensate during our Winter months. If testing in cold weather, give the patient time to warm up first!
Neuropad
Remove the plaster from the sleeve and stick to the plantar aspect of the 1st MTPJ. Leave in place for 600 seconds ( 10 minutes). After this period of time , note the colour of the plaster. In the well hydrated patient, the blue colour should change to pink. If the plaster remains blue or becomes mottled, then the patient is deemed to have some autonomic neuropathy present.
Ankle Jerk Reflex
May be done in one of two ways. Either with patient standing with one knee resting on a chair/seat with foot pointing down. Or with patient seated on a couch with leg rests, bend the knee slightly and externally rotate the leg so the Achilles tendon can be seen properly. Using a patella hammer, strike the Achilles tendon about 4cm above the calcaneal insertion point whilst applying gentle dorsiflectory pressure to the MTPJs. A positive reflex manifests as a plantarflectory “twitch”.
If your patient is high risk, or if you are in any doubt about the validity of your tests, REFER to the patients’ GP or to a general hospital diabetic foot clinic