Clinical examination for the detection of protective sensation in the feetof diabetic patients

OBJECTIVE: We compared the reproducibility and accuracy of conventional cli nical examination of the diabetic foot to monofilament examination. We also sought to simplify the monofilament examination by reducing it to fewer to uch points. METHODS: In a cross-sectional study at 10 centers in the United States, Can ada, and Switzerland, general internists and residents performed a structur ed history and physical examination for neuropathy on the feet of diabetic patients. Independent examination by two observers included monofilament se nsation, pinprick, vibration, position sense, and ankle reflexes. MAIN RESULTS: A total of 304 patients were examined by at least one practit ioner, and 200 received duplicate examinations. Monofilament examination an d ankle reflexes had the best reproducibility, with moderate agreement (kap pa = 0.59); pin-prick, position, and vibration sense had fair agreement (ka ppa = 0.28-0.38). No component of the history or physical examination, sing ly or in aggregate, was both sensitive and specific for identifying a patie nt with an abnormal monofilament examination. A simplified monofilament exa mination using only 4 sites per foot (total 8 sites) detected 90% of patien ts with an abnormal 16-site monofilament evaluation. CONCLUSIONS: Conventional clinical examination had low reproducibility and correlated poorly with monofilament examination for the identification of t he at-risk patient. The Semmes-Weinstein monofilament examination, a reprod ucible, valid, and generalizable test of foot sensation, is recommended as the screening procedure of choice for examining diabetic feet.