Evaluating the Competency of Your Diabetic Foot Treatment Team: Essential Skill #1: Assessing the Circulation to the Feet and Legs.

In these discussions, we discuss each of the 7 essential skills that your diabetes treatment team must use in order to help you prevent an amputation related to your diabetes.

Today we will discuss essential skill number one.

1. Assess the circulation (blood flow) to the feet and legs to determine the risk of gangrene.

There is a long-held joke among podiatrists that the only function of the heart is to pump the blood to the feet. The suggestion with this is the over-emphasis on the importance of delivering oxygenated blood to the tissues in the feet in order to keep a diabetic patient from developing a problem that might lead to premature death.

It is a well-researched fact that diabetics develop problems with their blood flow at a much faster rate than other people. This happens everywhere in the body. Through the process known as atherosclerosis (or hardening of the arteries) blood vessels become lined with plaques that are deposited over time. As these deposits increase, the diameter of the inside of the blood vessel becomes smaller and smaller, effectively decreasing blood flow.

This has been well documented in the coronary arteries of diabetic patients. We know that if you take two patients (one who is diabetic and one who is not) who are otherwise identical, the patient who has diabetes is four times more likely to have a heart attack. In large part this is due to the accelerated rate of atherosclerosis.

This same process occurs in the arteries of the feet and legs. Because of this process, the blood flow to the feet is dramatically reduced over time. Without blood flow, there is no oxygen delivered to the tissues. Without oxygen tissues die. Gangrene is nothing more than death of the tissue. Gangrene is one of the leading causes of amputation among diabetic patients.

With all of this is in mind, it is very easy to understand why your doctor must assess the blood flow to your feet. There are many ways to do so.

The simplest tests (and those most likely to be performed by any doctor evaluating a diabetic patient’s blood flow to the feet) involve a simple physical examination. During this exam, the doctor will likely attempt to feel the pulses behind the inside of your ankles (posterior tibial artery pulses) and on the tops of your feet (dorsalis pedis artery pulses). If the clinician is able to feel these pulses easily, the chances of developing extraordinarily bad blood flow known as critical limb ischemia are very small.

If the clinician is unable to feel these pulses, a hand-held Doppler device will typically be used in order to further evaluate the blood flow. This is a simple easy to perform test that does not cause any discomfort to the patient and can give a great deal of information about the state of blood flow.

More extensive tests are sometimes needed. Other tasks include transcutaneous oxygen pressure measurements (Tcp02), toe Doppler wave form analysis and toe pressures, and arterial duplex ultrasound.

If the results of these studies show severely compromised blood flow, it may be necessary to perform other more expensive exams including computed tomography angiography or magnetic resonance angiography. These are tests that use either CT scans are MRI evaluations to closely evaluate the state of blood flow in the feet and legs. They can provide an extraordinary amount of information but are oftentimes difficult to get approved by insurance companies due to their extraordinary cost.

The combined results of all of these exams are considered closely with the patient’s history, other physical exam findings and symptoms. In many cases all that is needed is continued monitoring of the patient. However, if findings warrant rapid intervention, it may be necessary to have an angioplasty or arterial stent placement in the leg in order to restore blood flow by a vascular surgeon. Other times an open arterial bypass is sometimes needed.

One thing that is clear is that delays in evaluation of the blood flow to the feet and legs can create huge problems. The most obvious of these would be development of gangrene as a result of critical limb ischemia that would make an amputation necessary.

The bottom line is that any doctor evaluating a diabetic patient should check (at the bare minimum) the pulses in both feet. If you see your diabetic doctor and the he/she does not ask you to take off of your shoes to evaluate the pulses in your feet, you should immediately find another doctor.


Dr. Christopher Segler is an author, inventor and award winning diabetic foot doctor. After discovering how amputations resulted from a failing health care system, it became his passion to teach strategies to stop diabetic amputation. If you have diabetes, you can learn more by requesting your FREE report “No Leg Left To Stand On: The Secrets Insurance Companies Don’t Want You To Know About Diabetic Foot Amputation” at http://www.ineedmyfeet.com.