DIABETIC FOOT EXAMINATION OSCE GUIDE

Lewis Potter
Endocrine

Diabetic foot examination frequently appears in OSCEs. Youll be expected to pick up the
relevant clinical signs using your examination skills. This diabetic foot examination OSCE
guide provides a clear, concise, step by step approach to examining diabetic feet.

Introduction
Wash hands
Introduce yourself
Confirm patient details name / DOB
Explain the examination
Gain consent
Position patient on bed at 45
Expose patients lower legs & feet

Gather equipment

Monofilament

Tuning fork (128hz)

Tendon hammer

Inspection
Inspect legs & feet thoroughly, lifting legs up to see underneath & ensuring to look between
toes.
Colour pallor / cyanosis /erythema (e.g. cellulitis / ischaemia)
Skin:
o

Dry / shiny / hair loss peripheral vascular disease

Eczema / haemosiderin staining venous disease

Ulcers inspect between toes / heels / underneath legs

o

Venous ulcers moderate to no pain larger /shallow associated with

venous insufficiency / varicose veins

Arterial ulcers very painful deep punched out appearance associated with diabetes
mellitus / peripheral vascular disease

Swelling:
o

Oedema e.g. venous insufficiency / heart failure

Deep vein thrombosis tender on palpation

Calluses may indicate incorrectly fitting shoes

Venous filling guttering of veins / reduced visibility suggests PVD
Deformity caused by neuropathy (e.g. Charcot arthropathy)


Inspect legs for hair loss / skin changes

Inspect limb colour


Inspect between toes for ulcers

Inspect behind legs for ulcers

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4.

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Palpation
Temperature cool (e.g. PVD) / hot (e.g. cellulitis)

Capillary refill normal = < 2 seconds prolongation suggests PVD

Pulses:
o

Dorsalis pedis artery lateral to EHL tendon

Posterior tibial artery posterior & inferior to medial malleolus

Absent peripheral pulses is suggestive of peripheral vascular disease.

Assess & compare leg temperature

Check capillary refill time


Palpate dorsalis pedis pulses

Palpate posterior tibial pulses


Palpate popliteal pulses

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5.

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Sensation
Monofilament
1. Provide an example of monofilament sensation on the patients arm / sternum
2. With the patients eyes closed, place monofilament on the hallux & metatarsal heads
(1/2/3/5)
3. Press firmly so that the filament bends
4. Hold the monofilament against the skin for 1-2 seconds ask patient to say when they
feel it
Avoid calluses / scars, as the patient will have reduced sensation in these areas.


Locations to place monofilament

Apply pressure until monofilament bends


Compare between feet

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3.

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Vibration sensation
1. Ask patient to close their eyes
2. Tap a 128hz tuning fork
3. Place onto patients sternum & confirm patient can feel it buzzing
4. Ask patient to tell you when they can feel it on their foot & to tell you when it stops buzzing
5. Place onto the distal phalanx of the great toe on each leg in turn
6. If sensation is impaired, continue to assess more proximally e.g. proximal phalanx

Assess vibration sensation

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Gait
Observe the patient walking whilst assessing:
o

Symmetry / balance

Turning quick / slow / staggered

Abnormalities broad based gait / foot drop / antalgia

Examine footwear:
o

Note pattern of wear on soles asymmetrical wearing gait abnormality

Ensure the shoes are the correct size for the patient

Note holes / material inside the shoes that could cause foot injury


Assess GAIT

Inspect footwear

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2.

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Other tests to consider

If abnormalities in monofilament or vibration sensation are identified, consider
carrying out further tests shown below.

Proprioception
1. Hold the distal phalanx of the great toe by its sides
2. Demonstrate movement of the toe upwards & downwards to the patient (whilst they
watch)
3. Then ask patient to close their eyes & state if you are moving the toe up or down
4. If the patient is unable to correctly identify direction of movement, move to a more
proximal joint ( ankle > knee > hip)

Assess proprioception
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Ankle jerk reflex

1. Dorsiflex the foot
2. Tap tendon hammer over the achilles tendon
3. Observe the calf for contraction normal reflex
Ankle jerk reflex may be absent in advanced peripheral neuropathy.

Assess ankle jerk reflex

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To complete the examination

Thank patient
Wash hands

Suggest further assessments & investigations

o

Full neurovascular assessment of the lower limbs

Bedside capillary blood glucose

Advice on good foot care