Section I

In the first section of the Foot Screen, the five questions can be answered in the Yes or No blank with an R, L, or B to indicate a positive or negative finding in the right, left, or both feet.

1. Has there been a change in the foot since the last evaluation?
On a first visit, enter N/A unless the inmate has noticed a change in strength or sensation within the past year. If that is the case, then check Yes. The purpose of this question is to determine from the inmate if he/she has perceived a change in the strength or sensation of their feet. Any change is significant in a foot screen. For example, an improvement in the inmate's perception of sensation could be a sign that the inmate is having a reversal of some of the neuropathic changes. Alternatively, if the inmate perceives a change for the worse, this could be a sign of worsening of the neuropathy.

2. Is there a foot ulcer now, or history of foot ulcer?
The purpose of this question is to determine if the inmate has now, or has ever had an ulcer on the foot. A positive history of a foot ulcer places the inmate permanently in Risk Category 3. Once an inmate has ulcerated, he or she is always at an increased risk of developing another foot ulcer. The inmate is also at risk of developing a progressive deformity of the foot and ultimately amputation of the lower extremity.

3. Does the foot have an abnormal shape?
This is determined by inspecting the general shape of the inmate's foot. Conditions to consider include: foot drop, eversion or inversion deformity, partial or complete amputations of the foot or toes, clawed toes, bunions, and especially a "Charcot Foot." A Charcot Foot is a foot which is moderately to severely deformed as a result of insensitivity and repeated injury. Fractures in an insensitive foot frequently fail to heal properly and can progress to the so-called boat shaped foot. These feet are at extreme risk of amputation and require immediate, expert care. A patient with a Charcot Foot is always in Category 3.

4. Is there weakness in the ankle or foot?
Unless the inmate has an open ulcer or infection of the foot, a rough estimate of strength can be made by asking the inmate to walk alternately on their heels and then on their toes.

5. Are the nails thick, too long, or ingrown?
If severe nail problems are present or if there is uncertainty about the vascular status of the toes, refer the inmate to an appropriate evaluator.

Section II

In the next section of the foot screen, the examiner does a sensory exam of the foot using the 10 gram monofilament and records the findings on the form in the circles on the foot drawing. There are ten places on each foot that are routinely tested. If the inmate can feel the filament, put a "+" in the appropriate circle. If they cannot feel it, put a "-". The sensory exam should be done in a quiet and relaxed setting, where the inmate can lie down. The inmate should not watch while the examiner applies the filament.

Section III

Next, examine the foot and record the problems identified by drawing or labeling as appropriate on the Foot Screen form. If there are callouses, pre-ulcerative lesions (a closed lesion, such as a blister or hematoma) or open ulcers, draw or describe them as accurately as possible. Then, draw in and label areas that are significantly red, warm (warmer than the other parts of the foot or the opposite foot), dry or macerated (friable, moist, soft tissue).

Section IV

This is the vascular assessment. Vascular studies are an important part of a foot evaluation in patients with diabetes and should at least include the palpation of pulses. More extensive evaluations such as doppler studies and angiography should be considered on a case by case basis.

Section V

Footwear is discussed under the appropriate Risk Category below.

Section VI

Risk Categorization: The accurate categorization of inmates into their respective Risk Category is a key element in the Foot Screen. The higher the Risk Category, the higher the risk an inmate has of recurrent foot ulceration, progressive deformity and ultimately, amputation of the foot.

Category 0: No loss of protective sensation. This is a patient who has essentially no risk of developing foot complications as a result of their disease. This patient does not need special footwear.

Category 1: Loss of protective sensation, no deformity or history of plantar ulceration. This patient has lost sensation to the point that they are defined as not having "protective sensation." These patients cannot feel the 10 gram monofilament and therefore cannot trust their sensation to prevent injury. The patients in this and the following two categories should never walk barefoot. They do not have enough sensation to prevent injuring themselves (e.g. as a result of stepping on sharp objects). Patients in this and the following two categories need to pay special attention to the fit and style of their shoes and should avoid pointed toed shoes or high heels. Category 1 patients do not need "custom" shoes. They usually do well in a jogging shoe or a well-fitting street shoe.

Category 2: Loss of protective sensation and deformity, no history of plantar ulceration. This patient, in addition to the loss of protective sensation, also has additional abnormalities, but has not progressed to the point of ulceration (current or past). They may need extra depth shoes with custom molded insoles to accommodate deformity of their feet. These patients can frequently wear a jogging shoe with a soft insert.

Category 3: History of plantar ulcer. This patient has loss of protective sensation and has progressed to the point of plantar ulceration (current or past). They will need extra depth shoes with soft molded inserts to accommodate any deformity of their feet. They may need custom-made shoes to manage their foot problems once their ulcer is healed.

FILAMENT APPLICATION INSTRUCTIONS
The sensory testing device used with the Foot Screen is a nylon filament mounted on a holder that has been standardized to deliver a 10 gram force when properly applied. Hansen's disease researchers have shown that a patient who can feel the 10 gram filament in selected sites are not at increased risk to develop ulcers.

1. Sites to be tested:
Dorsal foot: center of the top of the foot
Plantar foot:
(1) center of the heel pad
(2) medial arch
(3) "ball" of foot
(4) over distal 3rd metatarsal head
(5) over distal 5 metatarsal head
(6) over proximal 5th metatarsal
2. Apply the filament perpendicular to the skin's surface.
3. The approach, skin contact and departure of the filament should be approximately 1 1/2 seconds duration.
4. Apply sufficient force to cause the filament to bend.
5. Do not allow the filament to slide across the skin or make repetitive contact at the test site.
6. Randomize the selection of test sites and time between successive tests to reduce the potential for patient guessing.
7. Ask the patient to respond "yes" when the filament is felt and record the responses.
8. Apply the filament along the perimeter of and NOT on an ulcer site, callus, scar or necrotic tissue.

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Appendix 6