Semmes-Weinstein 10g monofilament applied to 10 plantar sites
Unable to detect monofilament = loss of protective sensation = HIGH ULCER RISK
128 Hz Tuning Fork
Vibration at hallux; if not felt, move up the limb
Loss of vibration = earliest sign of large fibre neuropathy
Ankle reflexes
Achilles tendon reflex
Absent reflex = neuropathy (sensitive early sign)
Temperature sensation
Cool vs warm stimulus
Loss = small fibre neuropathy
NCS (Nerve Conduction Studies)
Electrophysiology
GOLD STANDARD for diagnosis and classification
Annual diabetic foot screening should include: monofilament test + tuning fork + ankle reflexes + visual inspection + ABI (ankle brachial index). Every diabetic patient should have a documented foot risk category.
Diabetic Foot Risk Classification
Risk Category
Features
Review Frequency
Low risk
Normal sensation, normal perfusion, no deformity
Annual
Moderate risk
Neuropathy OR PAD OR deformity
Every 3–6 months
High risk
Neuropathy + PAD or deformity; previous ulcer
Every 1–3 months
Active foot problem
Ulceration, gangrene, or active Charcot
Immediate referral to multidisciplinary foot team
Glycaemic Optimisation — Primary Prevention
Intensive glycaemic control (HbA1c <53 mmol/mol / <7%) reduces neuropathy progression in T1DM (DCCT trial) and T2DM (UKPDS)
However, in established neuropathy, tight control has less impact — prevention is better than treatment
Aldose reductase inhibitors — limited clinical benefit; not standard therapy
Pharmacological Pain Management
Drug
Dose
Notes
Pregabalin (first-line)
75–300mg BD
α2δ calcium channel ligand; faster titration than gabapentin; sedation, weight gain, dizziness
Duloxetine (first-line)
60–120mg daily
SNRI; also indicated for depression and fibromyalgia; nausea on initiation
Amitriptyline (first-line)
10–75mg nocte
TCA; sedating — useful if sleep disruption from nocturnal pain; anticholinergic side effects
Gabapentin
300–1200mg TDS
Similar to pregabalin but slower titration; controlled drug in UK
Tramadol
50–100mg QDS
Weak opioid; second-line; dependence risk
Capsaicin cream/patch
0.025–0.075% cream; 8% patch
Topical; depletes substance P; burning sensation on application initially
Diabetic Foot Care — CRITICAL Nursing Interventions
Foot care education is one of the most important nursing interventions in diabetic neuropathy. A single missed foot inspection can lead to ulceration, infection, osteomyelitis, and amputation.
Daily foot inspection — patient self-inspection; use mirror for sole; carer inspection if vision impaired
Appropriate footwear — padded, well-fitting, no pressure points; custom orthotics for deformity
NO barefoot walking — ever (home or outdoors)
Nail care: file rather than cut; podiatrist for nail care (patient must NOT self-cut thick/deformed nails)
Check temperature of bath water with elbow (not foot) — prevent burns to insensate skin
Never use hot water bottles or heating pads on feet
Any new blister, ulcer, redness, or wound = seek medical attention same day
Charcot Arthropathy (Charcot Neuroarthropathy)
Charcot arthropathy = painless progressive joint destruction in an insensate foot. The foot appears warm, red, and swollen — often initially misdiagnosed as cellulitis or DVT. NO trauma is recalled.
Mechanism: repeated micro-trauma to insensate joints → bony destruction and remodelling → joint collapse (rocker-bottom foot deformity)
Midfoot most commonly affected
Acute Charcot: warm, swollen, erythematous foot; skin intact; often no pain despite dramatic appearance
Distinguish from osteomyelitis: MRI ± bone biopsy if uncertain
Treatment: total contact casting (TCC) — off-loads the foot completely; non-weight-bearing; serial casting for months
Do NOT elevate Charcot foot (this reduces blood flow needed for healing)
Bisphosphonates (pamidronate) — may reduce activity in acute Charcot; limited evidence
Autonomic Neuropathy Complications
Manifestation
Symptoms
Management
Gastroparesis
Nausea, vomiting, early satiety, bloating, erratic glucose control
Small frequent meals; prokinetics (metoclopramide, domperidone, erythromycin); avoid high-fat meals
Postural hypotension
Dizziness, syncope on standing; BP drop ≥20/10 mmHg on standing
Gradual position changes; compression stockings; fludrocortisone; midodrine
Erectile dysfunction
Impotence; often earliest autonomic symptom in males
GCC countries have some of the world's highest T2DM prevalence rates (UAE 20–25%, Saudi Arabia 20%+). With the largest diabetic populations in the region, diabetic neuropathy is extremely common. Foot complications are a major cause of hospitalisation and amputation in GCC hospitals.
Late diagnosis of T2DM is common — patients often have neuropathy at diagnosis
Suboptimal glycaemic control (HbA1c >9% common in GCC populations) accelerates neuropathy progression
Multidisciplinary diabetic foot clinics established in major hospitals — DHA, MOH, SEHA
Mosques: Muslims remove footwear before prayer — insensate feet on hard surfaces multiple times daily; footwear must be readily available immediately after prayer
Sandals: traditional sandal/flip-flop use exposes toes and soles to injury, pebbles, and heat
Desert heat: hot surfaces (sand, pavement) can burn insensate feet in minutes; maximum temperature of paved surfaces can exceed 70°C in UAE summer
Wading in water: sea and pool activities without footwear — lacerations not noticed
Nurses should specifically address these risks in foot care education, with culturally appropriate solutions (thin-soled mosque socks, appropriate beach footwear)
Diabetic Foot Services in GCC
Dubai Diabetes Centre — specialised multidisciplinary diabetic foot team including podiatrist, diabetologist, vascular surgeon, orthopaedic surgeon, nurse specialist
DHA and DOH diabetic foot pathways based on IWGDF (International Working Group on the Diabetic Foot) guidelines
Podiatry services expanding — previously limited; UK/Australian-trained podiatrists common in GCC private sector
Total contact casting available in specialist centres; vacuum-assisted closure (VAC) therapy for complex wounds
High-Yield Exam Points
50% of diabetics develop neuropathy after 10 years
Most common type = distal symmetrical polyneuropathy (DSPN) — "stocking then glove"; stocking distribution FIRST
Pain treatment first-line: pregabalin OR duloxetine (both first-line); also amitriptyline
Foot care = CRITICAL: daily inspection, emollient, no barefoot, appropriate footwear, podiatry for nails
Charcot arthropathy = painless joint destruction; warm swollen foot; NO trauma; total contact casting
Distinguish Charcot from osteomyelitis: MRI ± biopsy
Common Exam Traps
CN III palsy in diabetes = PUPIL SPARING (vascular infarction spares outer pupillomotor fibres). Pupil-involving CN III = surgical emergency (posterior communicating artery aneurysm)
Charcot foot looks like cellulitis/infection but is NOT infected — skin is intact; no fever; no pus
DO NOT elevate a Charcot foot — reduces healing blood flow; treat with offloading and total contact cast
Vibration sense (tuning fork) is the EARLIEST large fibre sign to disappear — test at great toe first
GCC Clinical Practice Insights
Mosque Foot Care Advice for GCC Diabetic Patients +
Muslims pray five times daily and remove footwear before entering mosques. For diabetic patients with neuropathy, this creates significant risk: hard marble/tile floors, other people's footwear, and prolonged standing. Advice: wear clean white cotton socks for prayer (permissible in many Islamic schools of thought to wipe over socks for wudu), inspect feet immediately after prayer, and wear shoes with thin soles inside the mosque if the mosque allows. Document this in patient education records.
Hot Surface Burns in GCC Summer — Insensate Feet +
During UAE and Saudi summer (June–September), pavement and sand surface temperatures can exceed 60–70°C. A patient with insensate feet may stand on or walk across these surfaces without feeling pain, sustaining full-thickness burns. These burns are painless, often unnoticed for hours, and frequently present as non-healing wounds requiring hospitalisation. Education: NEVER go barefoot outdoors in summer; check footwear temperature before putting on; use UV-protective, padded sandals.
Ramadan and Diabetic Neuropathy Pain Management +
Patients with painful diabetic neuropathy who fast during Ramadan may need their medication schedules adjusted. Pregabalin and amitriptyline can often be taken at suhoor and iftar. Duloxetine daily dosing is flexible. Topical treatments (capsaicin cream) remain fully compatible with fasting. Nurses should proactively counsel patients on adapting medication timing and ensuring continued pain management during the fasting month.
Pregabalin Prescribing and Misuse in GCC +
Pregabalin has been subject to misuse and diversion in some GCC populations. DHA and Saudi MOH have implemented stricter prescribing controls. Nurses should be aware that patients requesting dose escalation beyond therapeutic ranges or multiple early prescription requests may warrant further clinical assessment. In the UK (from 2019), pregabalin is a Schedule 3 controlled drug — this awareness informs GCC nursing practice standards.
Practice MCQs
Q1. A 55-year-old diabetic man develops sudden right-sided ptosis (drooping eyelid) and diplopia. The right pupil size is EQUAL to the left. What is the most likely diagnosis?
Correct answer: C — Diabetic CN III palsy is PUPIL-SPARING because the vascular infarction of the vasa nervorum affects the central motor fibres but spares the outer pupillomotor (parasympathetic) fibres. This is the classic distinguishing feature. A PComm aneurysm compresses CN III externally — affects pupillomotor fibres FIRST, causing a dilated fixed pupil. Pupil involvement in CN III palsy = neurosurgical emergency.
Q2. During annual diabetic foot screening, a patient cannot feel the 10g Semmes-Weinstein monofilament at any of the 10 plantar sites. What does this indicate?
Correct answer: A — Loss of 10g monofilament sensation indicates loss of protective sensation — the patient cannot feel sufficient pressure to protect the foot from ulceration. This places the patient in the HIGH RISK foot category. Immediate actions: intensified foot care education (daily inspection, appropriate footwear, no barefoot), increase review to every 1–3 months, refer to podiatry, and arrange vascular assessment if any signs of PAD.
Q3. A diabetic patient presents with a warm, red, painless, swollen right foot. There is no visible wound or ulcer. X-ray shows bony fragmentation of the midfoot joints. What is the diagnosis?
Correct answer: C — Classic Charcot arthropathy: painless swollen warm red foot + bony destruction on X-ray in a patient with diabetic neuropathy. Absence of pain despite dramatic appearance = loss of protective sensation. No wound excludes active infection as the primary diagnosis. Treatment: total contact casting, absolute non-weight-bearing. Do NOT elevate the limb. MRI ± bone biopsy if osteomyelitis cannot be excluded.
Q4. A diabetic patient with painful neuropathy asks which drug is recommended as first-line treatment. Which answer is correct?
Correct answer: C — Pregabalin (α2δ calcium channel ligand) and duloxetine (SNRI) are both NICE and international guideline first-line treatments for painful diabetic neuropathy. Amitriptyline is also first-line. NSAIDs have no efficacy in neuropathic pain. Opioids are second or third-line. Vitamin B12 treats B12 deficiency neuropathy — not standard treatment for diabetic neuropathy unless B12-deficient.