Abstract
OBJECTIVE: We compared the reproducibility and accuracy of conventional clinical examination of the diabetic foot to monofilament examination. We also sought to simplify the monofilament examination by reducing it to fewer touch points.
METHODS: In a cross-sectional study at 10 centers in the United States, Canada, and Switzerland, general internists and residents performed a structured history and physical examination for neuropathy on the feet of diabetic patients. Independent examination by two observers included monofilament sensation, pinprick, vibration, position sense, and ankle reflexes.
MAIN RESULTS: A total of 304 patients were examined by at least one practitioner, and 200 received duplicate examinations. Monofilament examination and ankle reflexes had the best reproducibility, with moderate agreement (κ=0.59); pinprick, position, and vibration sense had fair agreement (κ=0.28–0.36). No component of the history or physical examination, singly or in aggregate, was both sensitive and specific for identifying a patient with an abnormal monofilament examination. A simplified monofilament examination using only 4 sites per foot (total 8 sites) detected 90% of patients with an abnormal 16-site monofilament evaluation.
CONCLUSIONS: Conventional clinical examination had low reproducibility and correlated poorly with monofilament examination for the identification of the at-risk patient. The Semmes-Weinstein monofilament examination, a reproduible, valid, and generalizable test of foot sensation, is recommended as the screening procedure of choice for examining diabetic feet.
Similar content being viewed by others
References
Bild DE, Selby JV, Sinnock P, Browner WS, Braveman P, Showstack JA. Lower-extremity amputation in people with diabetes: epidemiology and prevention. Diabetes Care. 1989;12:24–31.
Boulton AJM. The diabetic foot: neuropathic in a etiology? Diabetic Med. 1990;7:852–8.
Harati Y. Diabetes and the nervous system. Endocrinology and Metab Clin of North Am. 1996;25:325–59.
Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care. 1990;131:513–21.
Nelson RG, Gohdes DM, Everhart JE, Hartner JA et al. Lower-extremity amputations in NIDDM: 12-yr follow-up study in Pima Indians. Diabetes Care. 1988;11:8–16.
Borssen B, Bergenheim T, Lithner F. Preventive treatment of foot deformities in type I diabetic patients aged 15–50 years—an epidemiological and prospective study. J Intern Med. 1996;240:219–25.
Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes. N Engl J Med. 1994;331:854–60.
Jaeschke R, Guyatt G, Sackett DL for the Evidence-Based Medicine Working Group. Users’ guides to the medical literature, III: how to use an article about a diagnostic test, A: are the results of the study valid? JAMA. 1994;271:389–91.
Jaeschke R, Guyatt G, Sackett DL for the Evidence-Based Medicine Working Group. Users’ guides to the medical literature, III: how to use an article about a diagnostic test, B: what are the results and will they help me in caring for my patients? JAMA. 1994;271:703–7.
Birke JA, Sims DS. Plantar sensory threshold in the ulcerative foot. Lepr Rev. 1986;57:261–7.
Boyko EJ, Smith DG, Ahroni JH. A prospective study of risk factors for diabetic foot ulcer. Rehab R&D Prog Report. 1994;318–9.
Holewski JJ, Stess RM, Graf PM, Grunfeld C. Aesthesiometry: quantification of cutaneous pressure sensation in diabetic peripheral neuropathy. J Rehab Res Dev. 1988;25:1–10.
McNeely MJ, Boyko EJ, Ahroni JH, et al. The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration: how great are the risks? Diabetes Care. 1995;18:216–9.
Olmos PR, Cataland S, O’Dorisio TM, Casey CA, Smead WL, Simon SR. The Semmes-Weinstein monofilament as a potential predictor of foot ulceration in patients with noninsulin-dependent diabetes. Am J Med Sci. 1995;309:76–82.
Sosenko JM, Kato M, Soto R, Bild DE. Comparison of quantitative sensory-threshold measures for their association with foot ulceration in diabetic patients. Diabetes Care. 1990;13:1057–61.
Gohdes D, Rith-Najarian S. Foot disease in diabetes. N Engl J Med. 1995;332:269–70. Letter.
Rith-Najarian SJ, Stolusky T, Gohdes DM. Identifying diabetic patients at high risk for lower-extremity amputation in a primary health care setting: a prospective evaluation of simple screening criteria. Diabetes Care. 1992;15:1386–9.
McCabe CJ, Stevenson RC, Dolan AM. Evaluation of a diabetic foot screening and protection programme. Diabetic Med. 1998;15:80–4.
Duffy JC, Patout CA. Management of the insensitive foot in diabetes: lessons learned from Hansen’s disease. Military Med. 1990;155:575–9.
Mueller MJ. Identifying patients with diabetes mellitus who are at risk for lower-extremity complications: use of Semmes-Weinstein monofilaments. Phys Ther. 1996;76:68–71.
Diamond JE, Mueller MJ, Delitto A, Sinacore DR. Reliability of a diabetic foot evaluation. Phys Ther. 1989;69:797–802.
Klenerman L, McCabe C, Cogley D, Crerand S, Laing P, White M. Screening for patients at risk of diabetic foot ulceration in a general diabetic outpatient clinic. Diabetic Med. 1996;13:561–3.
Valk GD, de Sonnaville JJJ, vanHoutum WH, et al. The assessment of diabetic polyneuropathy in daily clinical practice: reproducibility and validity of Semmes Weinstein monofilaments examination and clinical neurological examination. Muscle & Nerve. 1997;20:116–8.
Adler AI, Boyko EJ, Ahroni JH, Stensel V, Forsberg RC, Smith DG. Risk factors for diabetic peripheral sensory neuropathy: results of the Seattle Prospective Diabetic Foot Study. Diabetes Care. 1997;20:1162–7.
Sackett DL. A primer on the precision and accuracy of the clinical examination. JAMA. 1992;267:2638–44.
Edelman D, Sanders L, Pogach LM. Reproducibility and accuracy among primary care providers of a screening examination for foot ulcer risk among diabetic patients. Preventive Med. 1998;27(1):274–8.
Centers for Disease Control and Prevention. The prevention and treatment of complications of diabetes mellitus: a guide for primary care practitioners. January 1991.
Mayfield JA, Strand T, Toya AR. A call for specific codes for diabetes foot and eye care. Diabetes Care. 1995;18(3):418–21.
Author information
Authors and Affiliations
Consortia
Additional information
Dr. Edelman is supported by a VA Health Services Research Career Development Award.
The International Cooperative Group for Clinical Examination Research included the following site coordinators and participating centers: Durham Vetrans Affairs Center, Durham, NC (David Edelman, David Simel); Madigan Army Medical Center, Tacoma, Wash (Jeff Jackson); Mayo Clinic, Jacksonville, Fla (Mark Parkulo); McMaster University, Hamilton, Ont, Canada (Marek Smieja, Dereck Hunt, Jim Nishikawa, Herzel Gerstein, Rose Hatala); Minneapolis Veterans Affairs Hospital, Minneapolis, Minn (Craig Roth); San Antonio Veterans Affairs Hospital, San Antonio, Tex (John Williams); Universite de Lausanne, Switzerland (Jacques Cornuz, Maria Gueorguiev); University of Kentucky, Lexington, Ky (Don Holleman); University of Texas, San Antonio, Tex (Pat Wathen, Bob Badgett); University of Texas Southwestern, Dallas, Tex (Jim Wagner); University of Toronto, Toronto, Ont, Canada (Ed Etchells); and University of Wisconsin, Madison, Wis (Mae Hla).
Rights and permissions
About this article
Cite this article
Smieja, M., Hunt, D.L., Edelman, D. et al. Clinical examination for the detection of protective sensation in the feet of diabetic patients. J GEN INTERN MED 14, 418–424 (1999). https://doi.org/10.1046/j.1525-1497.1999.05208.x
Issue Date:
DOI: https://doi.org/10.1046/j.1525-1497.1999.05208.x