Deformity: clawed toes, bony prominences, Charcot joints (joint swelling with collapse of medial longitudinal arch β due to loss of protective pain sensation)
Trophic changes with bilateral callous formation and early ulceration
Charcot arthropathy
Arteriopathy assessment
Temperature: use dorsum of each hand to feel up legs
Sensory: show patient how each feels on sternum before and ask them to close their eyes
10g monofilament: fully extend the monofilament and press with enough force to make it bend. First let patient feel the sensation on their sternum, then ask them to close their eyes and tell you when they feel you touch their feet. Test sensation in multiple places, e.g. hallux and metatarsal heads.
128Hz Tuning fork: use your fingers to twang prongs and hold circular base on the patientβs joint. First let patient feel the sensation on their sternum, then ask them to close their eyes and tell you when they feel a vibration on their feet and when they feel it stop (stop the vibration yourself by gripping the prongs). Start over first MTP joint and move to proximal joints if the patient cannot feel it.
Proprioception: hold the distal phalanx of the big toe with a finger on each side (while stabilising the proximal phalanx with your other hand). Flex and extend the joint with the patient watching these movements and then ask them to close their eyes. Wiggle the distal phalanx up and down a few times, then stop and ask the patient if their toe is up or down. If they cannot tell, test more proximal joints in succession until they can.
Motor: muscle wasting, pes planus, pes cavus, Charcot joints
Reflexes: ankle jerk
Autonomic: sweaty, dry, cracked skin
To complete
Thank patient and restore clothing
βTo complete my examination, I would perform a full neurovascular examination.β
Summarise and suggest further investigations you would consider after a full history, for example: