I. Preparation & Initial Assessment

  • Introduce yourself and explain the procedure to the patient.
  • Perform hand hygiene.
  • Check baseline vitals and orthostatic vitals to ensure the patient is vitally stable before proceeding.

II. Inspection

  • Position the patient with feet propped up or clearly visible.
  • Skin & Tissue: Inspect for obvious deformities, erythema (redness), edema (swelling), drainage, discharge, or unexpected masses.
  • Wounds:
    • Classification/Grading: If any wounds or ulcers are found, grade them using the University of Texas Diabetic Wound Classification system.
  • Foot Shape & Deformities: Look at the arch and general structure of the feet.
    • Interpretation: Look for signs of Charcot foot, a noticeable deformity of the foot arch commonly caused by severe diabetic neuropathy.
  • Footwear Check: Examine the soles of the patient’s shoes (if available).
    • Interpretation: Check for uneven wear and tear, particularly on the medial aspect, which indicates abnormal pressure distribution.

III. Gait Assessment

  • Normal Walk: Ask the patient to walk normally across the room and observe.
    • Interpretation: Watch the pace and turning for staggering, slowness, or an antalgic gait (limping or staggering to account for pain).
  • Specialized Walk:
    • Ask the patient to walk on the tips of their toes (assessing for instability).
    • Ask the patient to walk on their heels.
  • Symptom Inquiry:
    • Interpretation: Ask the patient if they feel pain, numbness, tingling, or the sensation of “walking on cushions,” which are key subjective indicators of diabetic neuropathy.

IV. Neurological Examination (Sensory & Motor)

  • A. Light Touch Sensation (Monofilament Test)
    • Baseline: Test the monofilament on the patient’s chest/sternum first (with eyes closed) to establish the expected sensation.
    • Execution: With the patient’s eyes closed, tap specific landmarked areas on the top and the sole of the feet.
    • Response: The patient says “yes” each time they feel the touch.
  • B. Vibration Sensation (Tuning Fork Test)
    • Baseline: Strike the tuning fork and apply it to the sternum so the patient knows how the vibration feels.
    • Landmarks: Apply the tuning fork to the base and the head of the first metatarsal joint.
    • Execution: With the patient’s eyes closed, apply the vibrating fork.
    • Interpretation/Response: The patient must accurately state when they feel the vibration start and exactly when the vibration stops.
  • C. Proprioception (Joint Position Sense)
    • Technique: Grasp the big toe strictly by the sides. (Grasping top/bottom provides pressure cues that invalidate the test). Stabilize the joint with your other hand.
    • Baseline: Demonstrate “up” and “down” movements with the patient’s eyes open.
    • Execution: With the patient’s eyes closed, move the toe up or down.
    • Response: The patient must correctly identify the direction of movement. Repeat bilaterally.
  • D. Deep Tendon Reflexes (Achilles Tendon)
    • Positioning: Ensure the patient is relaxed, ideally with feet dangling off the edge of the examination table.
    • Execution: Hold the foot in slight dorsiflexion. Using a smooth arcing motion from the wrist, strike the Achilles tendon with a reflex hammer.
    • Grading/Interpretation: Note the reflex strength. A healthy, normal reflex is graded as +2 (perfect/normal Achilles tendon reflex).