It is sometimes difficult to decide if one foot is warmer than no

It is sometimes difficult to decide if one foot is warmer than normal (e.g. due to infection or Charcot foot) or, if in fact, the other foot is cooler due to PAD. Redness of the foot may occur in infection, but is also seen in severe PAD (Figure 1). PAD may also mask the inflammatory response to infection so learn more the

signs of infection may be very subtle or missed. Infection can also lead to discomfort or pain in the ischaemic foot and can be the trigger for the development of CLI in an ‘at risk’ foot. Palpation of the foot pulses includes the presence or absence of the posterior tibial, and dorsalis pedis pulses (up to 10% of the normal population do not have a palpable dorsalis pedis). It is exceedingly unusual to have a clearly palpable foot pulse in advanced CLI. The main exception to this would be distal small vessel embolisation causing localised tissue infarction. When there is uncertainty about the presence of a pulse it is best to assume that the pulse(s) is

absent and arrange further investigation. Assessment for any lower limb neuropathy is also vital.3,20 All people with diabetes should undergo annual foot screening, including palpation of foot pulses3,20 by a suitably trained health care professional,4 with subsequent classification of their current risk status, and a management plan then agreed with the patient. If found to be other than at low current risk (i.e. increased/moderate or high risk), without current active foot disease,

then they should receive review by a member of the ‘foot protection team’3,4 or a podiatrist20 at regular intervals.3,20–22 Although, as mentioned above, the diagnosis of CLI is highly unlikely in the presence of unless a clearly palpable foot pulse, the presence of a foot pulse does not exclude the diagnosis of PAD. ABPI may be useful in this situation as a supporting diagnostic test. Of course, all active foot disease, e.g. new (or deteriorating) foot ulcer, discolouration, swelling, or CLI (with or without tissue loss) should be referred rapidly (within 24 hours) to the specialist diabetes ‘multidisciplinary foot team’ (MDFT).3,20,22,23 Although further investigation is possible outside specialist centres, e.g. ABPI (see below), if CLI is suspected on the grounds of a simple but thorough history and examination, then urgent onward referral is indicated. For patients with diabetes and associated tissue loss or ulceration then this would usually be to the specialist diabetes MDFT. Where pain is the predominant symptom, without tissue loss, this may be to the vascular team depending on local pathways. No matter what the local pathway, it is vital that urgent referral and subsequent review are arranged.

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