Comprehensive Foot Examination and RiskAssessmentA report of the Task Force of the Foot Care Interest Group of the AmericanDiabetes Association, with endorsement by the American Association ofClinical Endocrinologists

ANDREW J.M. BOULTON, MD, FRCP1,2

DAVID G. ARMSTRONG, DPM, PHD3

STEPHEN F. ALBERT, DPM, CPED4

ROBERT G. FRYKBERG, DPM, MPH5

RICHARD HELLMAN, MD, FACP6,7

M. SUE KIRKMAN, MD8

LAWRENCE A. LAVERY, DPM, MPH9

JOSEPH W. LEMASTER, MD, MPH10

JOSEPH L. MILLS, SR., MD11

MICHAEL J. MUELLER, PT, PHD12

PETER SHEEHAN, MD13

DANE K. WUKICH, MD14

I t is now 10 years since the last technicalreview on preventative foot care waspublished (1), which was followed by

an American Diabetes Association (ADA)position statement on preventive foot carein diabetes (2). Many studies have beenpublished proposing a range of tests thatmight usefully identify patients at risk offoot ulceration, creating confusion amongpractitioners as to which screening testsshould be adopted in clinical practice. Atask force was therefore assembled by theADA to address and concisely summarizerecent literature in this area and then rec-ommend what should be included in thecomprehensive foot exam for adult pa-tients with diabetes. The committee wascochaired by the immediate past and cur-rent chairs of the ADA Foot Care InterestGroup (A.J.M.B. and D.G.A.), with otherpanel members representing primarycare, orthopedic and vascular surgery,physical therapy, podiatric medicine and

surgery, and the American Association ofClinical Endocrinologists.

THE PATHWAY TO FOOTULCERATIONThe lifetime risk of a person with diabetesdeveloping a foot ulcer may be as high as25%, whereas the annual incidence offoot ulcers is �2% (3–7). Up to 50% ofolder patients with type 2 diabetes haveone or more risk factors for foot ulceration(3,6). A number of component causes,most importantly peripheral neuropathy,interact to complete the causal pathway tofoot ulceration (1,3–5). A list of the prin-cipal contributory factors that might re-sult in foot ulcer development is providedin Table 1.

The most common triad of causesthat interact and ultimately result in ul-ceration has been identified as neuropa-thy, deformity, and trauma (5). Asidentification of those patients at risk of

foot problems is the first step in prevent-ing such complications, this report willfocus on key components of the footexam.

COMPONENTS OF THEFOOT EXAM

HistoryWhile history is a pivotal component ofrisk assessment, a patient cannot be fullyassessed for risk factors for foot ulcerationbased on history alone; a careful footexam remains the key component of thisprocess. Key components of the historyinclude previous foot ulceration or ampu-tation. Other important assessments inthe history (Table 2) include neuropathicor peripheral vascular symptoms (7,8),impaired vision, or renal replacementtherapy. Lastly, tobacco use should be re-corded, since cigarette smoking is a riskfactor not only for vascular disease butalso for neuropathy.

General inspectionA careful inspection of the feet in a well-litroom should always be carried out afterthe patient has removed shoes and socks.Because inappropriate footwear and footdeformities are common contributoryfactors in the development of foot ulcer-ation (1,5), the shoes should be inspectedand the question “Are these shoes appro-priate for these feet?” should be asked.

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From the 1Manchester Diabetes Centre, Manchester, U.K.; the 2Division of Endocrinology, Diabetes &Metabolism, University of Miami School of Medicine, Miami, Florida; the 3Dr. William M. Scholl Collegeof Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois;the 4Denver Department of Veterans Affairs Medical Center, Denver, Colorado; the 5Carl T. Hayden VAMedical Center, Phoenix, Arizona; the 6American Association of Clinical Endocrinologists, Jacksonville,Florida; the 7Department of Medicine, University of Missouri–Kansas City School of Medicine, KansasCity, Missouri; the 8American Diabetes Association, Alexandria, Virginia; the 9Department of Surgery,Texas A&M Health Science Center, Temple, Texas; the 10Department of Family & Community Medicine,University of Missouri–Columbia School of Medicine, Columbia, Missouri; the 11Department of Surgery,University of Arizona Health Sciences Center, Tucson, Arizona; the 12Program in Physical Therapy andDepartment of Radiology, Washington University School of Medicine, St. Louis, Missouri; the 13Depart-ment of Medicine, Mount Sinai School of Medicine, New York, New York; and the 14Department ofOrthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Corresponding author: Andrew J.M. Boulton, aboulton@med.miami.edu.This report was peer reviewed and approved by the Professional Practice Committee of the American

Diabetes Association, the Endocrine Practice Editorial Board, and the Board of Directors of the AmericanAssociation of Clinical Endocrinologists.

DOI: 10.2337/dc08-9021© 2008 by the American Diabetes Association. Readers may use this article as long as the work is properly

cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

Table 1—Risk factors for foot ulcers

• Previous amputation• Past foot ulcer history• Peripheral neuropathy• Foot deformity• Peripheral vascular disease• Visual impairment• Diabetic nephropathy (especially patients

on dialysis)• Poor glycemic control• Cigarette smoking

R e v i e w s / C o m m e n t a r i e s / A D A S t a t e m e n t sT A S K F O R C E R E P O R T

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Examples of inappropriate shoes includethose that are excessively worn or are toosmall for the person’s feet (too narrow, tooshort, toe box too low), resulting in rub-bing, erythema, blister, or callus. Featuresthat should be assessed during foot in-spection are outlined in Table 3 and arediscussed below.

Dermatological assessment. The der-matological assessment should initiallyinclude a global inspection, including in-terdigitally, for the presence of ulcerationor areas of abnormal erythema. The pres-ence of callus (particularly with hemor-rhage), nail dystrophy, or paronychiashould be recorded (9), with any of thesefindings prompting referral to a specialistor specialty clinic. Focal or global skintemperature differences between one footand the other may be predictive of eithervascular disease or ulceration and couldalso prompt referral for specialty foot care(10–13).Musculoskeletal assessment. The mus-culoskeletal assessment should includeevaluation for any gross deformity (14).Rigid deformities are defined as any con-tractures that cannot easily be manuallyreduced and are most frequently found inthe digits. Common forefoot deformitiesthat are known to increase plantar pres-sures and are associated with skin break-down include metatarsal phalangeal jointhyperextension with interphalangeal flex-ion (claw toe) or distal phalangeal exten-sion (hammer toe) (15–17). (Examples ofthese deformities are shown in Fig. 1.)

An important and often overlookedor misdiagnosed condition is Charcot ar-thropathy. This occurs in the neuropathicfoot and most often affects the midfoot.This may present as a unilateral red, hot,swollen, flat foot with profound defor-mity (18–20). A patient with suspectedCharcot arthropathy should be immedi-ately referred to a specialist for furtherassessment and care.

Neurological assessmentPeripheral neuropathy is the most com-mon component cause in the pathway todiabetic foot ulceration (1,4,5,7). Theclinical exam recommended, however, isdesigned to identify loss of protective sen-sation (LOPS) rather than early neuropa-thy. The diagnosis and management ofthe latter were covered in a 2004 ADAtechnical review (7). The clinical exami-nation to identify LOPS is simple and re-quires no expensive equipment.

Five simple clinical tests (Table 3),each with evidence from well-conductedprospective clinical cohort studies, areconsidered useful in the diagnosis ofLOPS in the diabetic foot (1–7). The taskforce agrees that any of the five tests listedcould be used by clinicians to identifyLOPS, although ideally two of theseshould be regularly performed during the

screening exam—normally the 10-gmonofilament and one other test. One ormore abnormal tests would suggestLOPS, while at least two normal tests (andno abnormal test) would rule out LOPS.The last test listed, vibration assessmentusing a biothesiometer or similar instru-ment, is widely used in the U.S.; however,identification of the patient with LOPScan easily be carried out without this orother expensive equipment.10-g monofilaments. Monofilaments,sometimes known as Semmes-Weinsteinmonofilaments, were originally used todiagnose sensory loss in leprosy (21).Many prospective studies have confirmedthat loss of pressure sensation using the10-g monofilament is highly predictive ofsubsequent ulceration (3,21,22). Screen-ing for sensory loss with the 10-g mono-filament is in widespread use across theworld, and its efficacy in this regard hasbeen confirmed in a number of trials, in-cluding the recent Seattle Diabetic FootStudy (4,21,23,24).

Nylon monofilaments are con-structed to buckle when a 10-g force isapplied; loss of the ability to detect thispressure at one or more anatomic sites onthe plantar surface of the foot has beenassociated with loss of large-fiber nervefunction. It is recommended that foursites (1st, 3rd, and 5th metatarsal headsand plantar surface of distal hallux) betested on each foot.

The technique for testing pressureperception with the 10-g monofilament isillustrated in Fig. 2; patients should closetheir eyes while being tested. Caution isnecessary when selecting the brand ofmonofilament to use, as many commer-cially available monofilaments have beenshown to be inaccurate. Single-use dis-posable monofilaments or those shown tobe accurate by the Booth and Young (23)study are recommended. The sensation ofpressure using the buckling 10-g mono-filament should first be demonstrated tothe patient on a proximal site (e.g., upperarm). The sites of the foot may then beexamined by asking the patient to re-spond “yes” or “no” when asked whetherthe monofilament is being applied to theparticular site; the patient should recog-nize the perception of pressure as well asidentify the correct site. Areas of callusshould always be avoided when testingfor pressure perception.128-Hz tuning forks. The tuning fork iswidely used in clinical practice and pro-vides an easy and inexpensive test of vi-bratory sensation. Vibratory sensation

Table 2—Essential features of history

Past history• ulceration• amputation• Charcot joint• vascular surgery• angioplasty• cigarette smoking

Neuropathic symptoms• positive (e.g., burning or shooting

pain, electrical or sharp sensations,etc.)

• negative (e.g., numbness, feet feeldead)

Vascular symptoms• claudication• rest pain• nonhealing ulcer

Other diabetes complications• renal (dialysis, transplant)• retinal (visual impairment)

Table 3—Key components of the diabetic footexam

InspectionDermatologic

• skin status: color, thickness, dryness,cracking

• sweating• infection: check between toes for

fungal infection• ulceration• calluses/blistering: hemorrhage into

callus?Musculoskeletal

• deformity, e.g., claw toes, prominentmetatarsal heads, Charcot joint (Fig. 1)

• muscle wasting (guttering betweenmetatarsals)

Neurological assessment10-g monofilament � 1 of the following 4

• vibration using 128-Hz tuning fork• pinprick sensation• ankle reflexes• VPT

Vascular assessment• foot pulses• ABI, if indicated

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should be tested over the tip of the greattoe bilaterally. An abnormal response canbe defined as when the patient loses vi-bratory sensation and the examiner stillperceives it while holding the fork on thetip of the toe (3,4).Pinprick sensation. Similarly, the in-ability of a subject to perceive pinpricksensation has been associated with an in-creased risk of ulceration (4). A dispos-able pin should be applied just proximalto the toenail on the dorsal surface of thehallux, with just enough pressure to de-

form the skin. Inability to perceive pin-prick over either hallux would beregarded as an abnormal test result.Ankle reflexes. Absence of ankle re-flexes has also been associated with in-creased risk of foot ulceration (4). Anklereflexes can be tested with the patient ei-ther kneeling or resting on a couch/table.The Achilles tendon should be stretcheduntil the ankle is in a neutral position be-fore striking it with the tendon hammer. Ifa response is initially absent, the patientcan be asked to hook fingers together and

pull, with the ankle reflexes then retestedwith reinforcement. Total absence of an-kle reflex either at rest or upon reinforce-ment is regarded as an abnormal result.Vibration perception threshold testing.The biothesiometer (or neurothesiom-eter) is a simple handheld device thatgives semiquantitative assessment of vi-bration perception threshold (VPT). Asfor vibration using the 128-Hz tuningfork, vibration perception using thebiothesiometer is also tested over the pulpof the hallux. With the patient lying su-

Figure 1—Foot deformities. These sites are frequent locations for diabetic foot ulceration. A: Claw toe deformity. Note the buckling phenomenon thatcauses increased pressure on the dorsal hammer digit deformity, as well as on the plantar metatarsal head. B: Bunion and overlapping toes. Thisdeformity can lead to pressure ulceration between the digits, on the dorsal or plantar surfaces of displaced digits, and over the medial firstmetatarsophalangeal joint. C: A rocker-bottom deformity secondary to Charcot arthropathy can cause excessive pressure at the plantar midfoot,increasing risk for ulceration at that site.

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pine, the stylus of the instrument is placedover the dorsal hallux and the amplitudeis increased until the patient can detectthe vibration; the resulting number isknown as the VPT. This process shouldinitially be demonstrated on a proximalsite, and then the mean of three readingsis taken over each hallux. A VPT �25 V isregarded as abnormal and has beenshown to be strongly predictive of subse-quent foot ulceration (15,22).

Vascular assessmentPeripheral arterial disease (PAD) is a com-ponent cause in approximately one-thirdof foot ulcers and is often a significant riskfactor associated with recurrent wounds(5,25). Therefore, the assessment of PADis important in defining overall lower-

extremity risk status. Vascular examina-tion should include palpation of theposterior tibial and dorsalis pedis pulses(10,26), which should be characterized aseither “present” or “absent” (26).

Diabetic patients with signs or symp-toms of vascular disease (Table 2) or ab-sent pulses on screening foot examinationshould undergo ankle brachial pressureindex (ABI) pressure testing and be con-sidered for a possible referral to a vascularspecialist. The ABI is a simple and easilyreproducible method of diagnosing vas-cular insufficiency in the lower limbs.Blood pressure at the ankle (dorsalis pedisor posterior tibial arteries) is measuredusing a standard Doppler ultrasonicprobe. This technique is outlined in Fig.3. The ABI is obtained by dividing the

ankle systolic pressure by the higher ofthe two brachial systolic pressures (8). AnABI �0.9 is normal, �0.8 is associatedwith claudication, and �0.4 is commonlyassociated with ischemic rest pain andtissue necrosis.

The ADA Consensus Panel on PADrecommended measurement of ABI in di-abetic patients over 50 years of age andconsideration of ABI measurement inyounger patients with multiple PAD riskfactors, repeating normal tests every 5years (8). ABI may therefore be part of theannual comprehensive foot exam in thesepatient subgroups. ABI measurementsmay be misleading in diabetes because thepresence of medial calcinosis renders thearteries incompressible and results infalsely elevated or supra-systolic ankle

Figure 2—Upper panel: For performance of the 10-g monofilament test, the device is placed perpendicular to the skin, with pressure applied untilthe monofilament buckles. It should be held in place for �1 s and then released. Lower panel: The monofilament test should be performed at thehighlighted sites while the patient’s eyes are closed.

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pressures. In the presence of incompress-ible calf or ankle arteries (ABI �1.3),measurements of digital arterial systolicpressure (toe pressure) or transcutaneousoxygen tension may be performed.

Risk classification and referral/follow-upOnce the patient has been thoroughly as-sessed as described above, he or sheshould be assigned to a foot risk category(Table 4). These categories are designedto direct referral and subsequent therapyby the specialty clinician or team (17,20)and frequency of follow-up by the gener-alist or specialist. Increased category is as-

sociated with an increased risk forulceration, hospitalization, and amputa-tion (17). Patients in risk category 0 gen-erally do not need referral and shouldreceive general foot care education andundergo comprehensive foot examina-tion annually. Patients in foot risk cate-gory 1 may be managed by a generalist orspecialist every 3–6 months. Consider-ation should be given to an initial special-ist referral to assess the need forspecialized treatment and follow-up.Those in categories 2 and 3 should be re-ferred to a foot care specialist or specialtyclinic and seen every 1–3 months.

CONCLUSIONS — It cannot be over-stated that the complications of the dia-betic foot are common, complex, andcostly, mandating aggressive and proac-tive preventative assessments by general-ists and specialists. All patients withdiabetes must have their feet evaluated atleast at yearly intervals for the presence ofthe predisposing factors for ulcerationand amputation (neuropathy, vasculardisease, and deformities). This reportsummarizes a simple protocol for doingso. If abnormalities are present, more fre-quent evaluation of the diabetic foot isrecommended depending on risk cate-gory, as described above and in Table 4.

Figure 3—Lower-extremity circulation and the ABI test. A: Anterior view, right lower limb, normal arterial anatomy. B: ABI. Place blood pressurecuff above pulse. Place Doppler probe over arterial pulse; a: posterior tibial artery, b: dorsalis pedis artery. ABI calculation: Divide ankle systolicblood pressure by brachial artery systolic blood pressure. (ABI �0.9 is normal.) Adapted from Khan et al., JAMA 295:536–546, 2006.

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It is through systematic examinationand risk assessment, patient education,and timely referral that we may furtherreduce the unnecessarily high preva-lence of lower-extremity morbidity in thispopulation.

Acknowledgments— The meeting of theTask Force was supported by an unrestrictededucational grant from KCI, San Antonio, TX.

A.J.M.B. has received honoraria/consultingfees from Pfizer and Eli Lilly. R.G.F. has servedon the speakers’ bureaus of KCI, Oculus,Pfizer, and Organogenesis and has received re-search support from Regenesis Biomedical andDerma Sciences. L.A.L. is a stockholder and onthe board of directors of Diabetica Solutionsand Pathways Disease Management; a stock-holder of XL Health; on the scientific advisoryboard and speakers’ bureau of and has re-ceived research support from KCI; and astockholder and on the scientific advisoryboards of Cytomedics and Pegasus. P.S. is onthe scientific advisory boards of AdvancedBiohealing and Greystone; a consultant forCalretex, Cardiun, Heal Or, Taisho, and Hy-permed; a speaker for Fox Hollow, Bristol-Meyers Squibb, sanofi-aventis, Merck, andOrganogenesis; and has received researchgrants from Tissue Repair Company, Baxter,and PamLab. D.K.W. has received honorariafrom Small Bones Innovation, Diabetic GlobalFoot Conference, and New Horizons in Cardio-vascular Medicine.

References1. Mayfield JA, Reiber GE, Sanders LJ,

Janisse D, Pogach LM: Preventive footcare in people with diabetes. Diabetes Care21:2161–2177, 1998

2. American Diabetes Association: Preventa-

tive foot care in people with diabetes. Di-abetes Care 26 (Suppl. 1):S78–S79, 2003

3. Singh N, Armstrong DG, Lipsky BA: Pre-venting foot ulcers in patients with diabe-tes. JAMA 293:217–228, 2005

4. Abbott CA, Carrington AL, Ashe H, BathS, Every LC, Griffiths J, Hann AW, Hus-sain A, Jackson N, Johnson KE, Ryder CH,Torkington R, Van Ross ER, Whalley AM,Widdows P, Williamson S, Boulton AJ:The North-West Diabetes Foot CareStudy: incidence of, and risk factors for,new diabetic foot ulceration in a commu-nity-based patient cohort. Diabet Med 19:377–384, 2002

5. Reiber GE, Vileikyte L, Boyko EJ, delAguila M, Smith DG, Lavery LA, BoultonAJ: Causal pathways for incident lower-extremity ulcers in patients with diabetesfrom two settings. Diabetes Care 22:157–162, 1999

6. Boulton AJ, Kirsner RS, Vileikyte L: Clin-ical practice: neuropathic diabetic foot ul-cers. N Engl J Med 351:48–55, 2004

7. Boulton AJ, Malik RA, Arezzo JC, SosenkoJM: Diabetic somatic neuropathies. Diabe-tes Care 27:1458–1486, 2004

8. American Diabetes Association: Periph-eral arterial disease in people with diabe-tes (Consensus Statement). Diabetes Care26:3333–3341, 2003

9. Bristow I: Non-ulcerative skin patholo-gies of the diabetic foot. Diabetes MetabRes Rev 24 (Suppl. 1):S84–S89, 2008

10. McGee SR, Boyko EJ: Physical examina-tion and chronic lower-extremity isch-emia: a critical review. Arch Intern Med158:1357–1364, 1998

11. Lavery LA, Higgins KR, Lanctot D, Con-staninides GP, Zamorano RG, AthanasiouKA, Armstrong DG, Agrawal CM: Pre-venting diabetic foot ulcer recurrence inhigh-risk patients: the use of temperature

monitoring as a self-assessment tool. Dia-betes Care 30:14–20, 2007

12. Armstrong DG, Holtz-Neiderer K, Wen-del CS, Mohler MJ, Kimbriel HR, LaveryLA: Skin temperature monitoring reducesthe risk for diabetic foot ulceration inhigh-risk patients. Am J Med 120:1042–1046, 2007

13. Lavery LA, Higgins KR, Lanctot DR, Con-stantinides GP, Zamorano RG, ArmstrongDG, Athanasiou KA, Agrawal CM: Homemonitoring of foot skin temperatures toprevent ulceration. Diabetes Care 27:2642–2647, 2004

14. Frykberg RG, Zgonis T, Armstrong DG,Driver VR, Giurini JM, Kravitz SR, Lands-man AS, Lavery LA, Moore JC, SchuberthJM, Wukich DK, Andersen C, Vanore JV:Diabetic foot disorders: a clinical practiceguideline (2006 revision). J Foot AnkleSurg 45 (Suppl. 5):S1–S66, 2006

15. Young MJ, Breddy JL, Veves A, BoultonAJ: The prediction of diabetic neuropathicfoot ulceration using vibration perceptionthresholds: a prospective study. DiabetesCare 17:557–560, 1994

16. Mueller MJ, Hastings MK, CommeanPK, Smith KE, Pilgram TK, RobertsonD, Johnson J: Forefoot structural pre-dictors of plantar pressures duringwalking in people with diabetes and pe-ripheral neuropathy. J Biomech 36:1009 –1017, 2003

17. Lavery LA, Armstrong DG, Vela SA,Quebedeaux TL, Fleischli JG: Practicalcriteria for screening patients at high riskfor diabetic foot ulceration. Arch InternMed 158:157–162, 1998

18. Armstrong DG, Todd WF, Lavery LA,Harkless LB, Bushman TR: The naturalhistory of acute Charcot’s arthropathy in adiabetic foot specialty clinic. Diabet Med14:357–363, 1997

Table 4—Risk classification based on the comprehensive foot examination

Risk category Definition Treatment recommendations Suggested follow-up

0 No LOPS, no PAD, no deformity • Patient education including advice onappropriate footwear.

Annually (by generalist and/or specialist)

1 LOPS � deformity • Consider prescriptive oraccommodative footwear.

Every 3–6 months (by generalist orspecialist)

• Consider prophylactic surgery ifdeformity is not able to be safelyaccommodated in shoes. Continuepatient education.

2 PAD � LOPS • Consider prescriptive oraccommodative footwear.

Every 2–3 months (by specialist)

• Consider vascular consultation forcombined follow-up.

3 History of ulcer or amputation • Same as category 1. Every 1–2 months (by specialist)• Consider vascular consultation for

combined follow-up if PAD present.

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19. Apelqvist J, Bakker K, van Houtum WH,Nabuurs-Franssen MH, Schaper NC:International consensus and practicalguidelines on the management and theprevention of the diabetic foot: Interna-tional Working Group on the DiabeticFoot. Diabete Metab Res Rev 16 (Suppl.1):S84–S92, 2000

20. Lavery LA, Peters EJ, Williams JR, Mur-doch DP, Hudson A, Lavery DC: Reeval-uating how we classify the diabetic foot:restructuring the diabetic foot risk classi-fication system of the International Work-ing Group on the Diabetic Foot. DiabetesCare 31:154–156, 2008

21. Mayfield JA, Sugarman JR: The use of theSemmes-Weinstein monofilament andother threshold tests for preventing footulceration and amputation in personswith diabetes. J Fam Pract 49 (Suppl. 11):S17–S29, 2002

22. Armstrong DG, Lavery LA, Vela SA,Quebedeaux TL, Fleischli JG: Choosing apractical screening instrument to identifypatients at risk for diabetic foot ulcer-ation. Arch Intern Med 158:289–292,1998

23. Booth J, Young MJ: Differences in the per-formance of commercially available 10-gmonofilaments. Diabetes Care 23:984–

988, 200024. Boyko EJ, Ahroni JH, Cohen V, Nelson

KM, Heagerty PJ: Prediction of diabeticfoot ulcer occurrence using commonlyavailable clinical information: the SeattleDiabetic Foot Study. Diabetes Care 29:1202–1207, 2006

25. Peters EJ, Armstrong DG, Lavery LA: Riskfactors for recurrent diabetic foot ulcers:site matters. Diabetes Care 30:2077–2079, 2007

26. Khan NA, Rahim SA, Anand SS, Simel DL,Panju A: Does the clinical examinationpredict lower extremity peripheral arterialdisease? JAMA 295:536–546, 2006

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