4.2.0.0 Eval­u­a­tion for Loss of Pro­tec­tive Sen­sa­tion

All adults with di­a­betes should un­der­go a com­pre­hen­sive foot eval­u­a­tion at least an­nu­al­ly. De­tailed foot as­sessments may occur more fre­quent­ly in pa­tients with his­to­ries of ul­cers or am­pu­ta­tions, foot de­for­mi­ties, in­sen­sate feet, and PAD (145). To as­sess risk, clin­i­cians should ask about his­to­ry of foot ul­cers or am­pu­ta­tion, neu­ro­path­ic and pe­riph­er­al vas­cu­lar symp­toms, im­paired vi­sion, renal dis­ease, to­bac­co use, and foot care prac­tices. A gen­er­al in­spec­tion of skin in­tegri­ty and mus­cu­loskele­tal de­for­mi­ties should be per­formed. Vas­cu­lar as­sessment should in­clude in­spec­tion and pal­pa­tion of pedal puls­es.

The neu­ro­log­i­cal exam per­formed as part of the foot ex­am­i­na­tion is de­signed to iden­tify LOPS rather than early neu­ropa­thy. The 10-g monofilament is the most use­ful test to di­ag­nose LOPS. Ide­al­ly, the 10-g monofilament test should be per­formed with at least one other as­sessment (pin­prick, tem­per­a­ture or vi­bra­tion sen­sa­tion using a 128-Hz tun­ing fork, or ankle reflexes). Ab­sent monofilament sen­sa­tion sug­gests LOPS, while at least two nor­mal tests (and no abnor­mal test) rules out LOPS.