A diabetic foot exam takes about ten minutes and its whole purpose is to answer one question before you can feel the answer yourself: can this foot still warn you when something is wrong?
The short version
The examination has four parts: sensation, circulation, skin and structure. Sensation is tested with a 10-gram monofilament and a tuning fork; circulation with pulses and, when indicated, pressure measurements; skin and nails are inspected everywhere including between the toes; structure means deformity and where your weight actually lands.
The output is a risk category, and the risk category sets how often you should be seen — from once a year to every month. Everyone with diabetes should have this at least annually, whether or not anything hurts.
Sensation: the 10-gram monofilament
A monofilament is a short nylon strand calibrated to buckle at exactly ten grams of force. It is pressed against defined sites on the sole until it bends, and you say whether you felt it — with your eyes closed, so you are reporting sensation rather than sight.
Failure to feel it at one or more sites means loss of protective sensation. That single finding is the most important thing the examination produces, because it is the strongest predictor of future ulceration and it changes everything downstream: footwear, how often you are seen, and whether you can safely do your own nail care.
Two things the monofilament is not
It is not a test of whether you have neuropathy — small-fibre neuropathy can cause burning pain with an intact monofilament. And a normal result is not permission to ignore the foot. It measures one specific thing: whether protective sensation is still there.
A 128 Hz tuning fork on the bony prominence of the big toe adds vibration sense, which is often lost earlier than pressure sense. Together they give a fuller picture than either alone.
Circulation, and why a normal number can lie
Pulses are felt at the top of the foot and behind the inner ankle. Absent pulses, or symptoms like cramping in the calf at a predictable walking distance, prompt formal testing.
Ankle-brachial index
Ankle pressure divided by arm pressure. Straightforward, widely available — and, in diabetes, prone to reading falsely high.
Why it reads high
Long-standing diabetes calcifies the artery walls. A stiff, calcified vessel resists compression, so the cuff records a higher pressure than the blood inside justifies.
Toe pressure and TBI
Toe arteries calcify far less, so toe pressure and the toe-brachial index are the more trustworthy measurement in a diabetic foot.
What comes next
Poor numbers, or a wound that will not heal, lead to duplex imaging or angiography and a vascular opinion. Blood supply decides whether anything heals.
The practical version: a normal ABI in a diabetic foot is not proof of good circulation. If you have a wound that is not progressing and someone has reassured you on an ABI alone, that is worth questioning.
Skin, nails and structure
- Callus, particularly over a bony prominence — and especially callus with a dark spot inside it, which is bleeding underneath and is a pre-ulcer.
- Between the toes, for damp, white, split skin. Fungal infection there opens the door for bacteria.
- Fissures at the heel, and skin quality generally — dry, inelastic skin in a foot that no longer sweats.
- Nails — thickened, crumbling, ingrowing, or pressing on the nail bed.
- Deformity — clawed toes, bunions, dropped metatarsal heads, a collapsed arch, or the rocker-bottom shape of a previous Charcot event.
- Temperature difference between the two feet, compared at the same sites. One foot markedly warmer than the other is a finding, not a curiosity.
- Your shoes. A good examiner looks at what you walked in with: wear pattern, depth, and whether the inside has anything in it that should not be there.
What the risk category means for you
| Category | What it describes | Typical review interval |
|---|---|---|
| Very low | No loss of protective sensation and no peripheral arterial disease | Once a year |
| Low | Loss of protective sensation or peripheral arterial disease | Every six to twelve months |
| Moderate | Loss of protective sensation plus arterial disease, or either one plus foot deformity | Every three to six months |
| High | Any of the above plus a history of foot ulcer, lower-extremity amputation, or end-stage kidney disease | Every one to three months |
Two things worth noticing. The intervals are driven by findings, not by symptoms — a high-risk foot that feels fine still needs monthly eyes on it. And a previous ulcer never comes back off your record: roughly two thirds of healed ulcers recur within three to five years, which is why that history alone puts you in the top category.
How to get the most out of the appointment
- Bring the shoes you wear most, not your best pair, plus any inserts or braces even if you have stopped using them.
- Do not treat anything beforehand. No filing, no cutting, no covering a callus. We need to see it as it is.
- Say when a change started, even vaguely. “About two months” separates an acute problem from a chronic one and changes the plan.
- Ask for your risk category and your review interval in writing. If you leave without knowing both, the examination has not finished doing its job.
- Ask what your feet should look like in a month — a concrete answer gives you something to compare against at home.
Common questions
How often should a person with diabetes have a foot exam?
At least once a year for everyone with diabetes. More often once findings appear: every six to twelve months with sensation loss or arterial disease, every three to six months if deformity is also present, and every one to three months with a history of ulcer, amputation or end-stage kidney disease. The interval follows the findings, not the symptoms.
Does Medicare cover a diabetic foot exam?
Medicare Part B generally covers a foot examination every six months for people with diabetes-related peripheral neuropathy and loss of protective sensation, provided you have not seen a foot care professional for another reason in between. Routine foot care in the absence of a qualifying condition is a different matter and is usually excluded. Coverage depends on documentation, so ask the practice before assuming.
What is a 10-gram monofilament testing exactly?
Whether you can feel ten grams of pressure on the sole — that is, whether protective sensation is intact. It is not a general test for neuropathy: you can have painful small-fibre neuropathy and still feel the monofilament perfectly. It answers one question, and it answers it well.
Can I check my own feet instead?
Daily self-inspection is essential and nobody else can do it for you — but it is not the same thing. You cannot test your own protective sensation reliably, you cannot measure your own circulation, and you cannot see the pattern of pressure your own gait creates. Do both: look every day, and get examined at the interval your risk category sets.
Nothing hurts. Do I still need this?
Yes, and that is precisely the point. The most dangerous diabetic foot is the one that has stopped hurting, because the alarm has been disconnected while the risk keeps climbing. Painless is not the same as fine.
Sources
Clinical literature retrieved from PubMed, plus the governing federal sources.
- American Diabetes Association Professional Practice Committee. 12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes—2026. Diabetes Care. 2026;49(Suppl 1):S261-S276. doi:10.2337/dc26-S012 — what a comprehensive foot evaluation includes, and the recommendation to pair the 10-gram monofilament with at least one other sensory assessment in the same exam.
- Pop-Busui R, Boulton AJ, Feldman EL, et al. Diabetic Neuropathy: A Position Statement by the American Diabetes Association. Diabetes Care. 2017;40(1):136-154. doi:10.2337/dc16-2042 — the monofilament as a large-fibre test, and why small-fibre neuropathy can burn with the monofilament still intact.
- Devigili G, Tugnoli V, Penza P, et al. The diagnostic criteria for small fibre neuropathy: from symptoms to neuropathology. Brain. 2008;131(7):1912-1925. doi:10.1093/brain/awn093 — small-fibre neuropathy escaping routine electrophysiological testing.
- Chuter V, Schaper N, Mills J, et al. Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: A systematic review. Diabetes Metab Res Rev. 2024;40(3):e3683. doi:10.1002/dmrr.3683 — the finding that an ABI in the normal range does not exclude peripheral arterial disease in diabetes.
- Abbade LPF, Frade MAC, Pegas JRP, et al. Consensus on the diagnosis and management of chronic leg ulcers – Brazilian Society of Dermatology. Anais Brasileiros de Dermatologia. 2020;95:1-18. doi:10.1016/j.abd.2020.06.002 — arterial calcification making vessels non-compressible, and hallux pressure as the measurement to use instead.
- Schaper NC, van Netten JJ, Apelqvist J, et al. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3657. doi:10.1002/dmrr.3657 — the IWGDF risk stratification table and its review intervals.
- Centers for Medicare & Medicaid Services. Foot care (for diabetes). Medicare.gov. medicare.gov/coverage/foot-care-for-diabetes — Part B covering a foot exam every six months with diabetic peripheral neuropathy and loss of protective sensation.
Related guides
Diabetic neuropathy ICD-10 codes
How the exam findings written in the note become E11.40 or E11.42.
What diabetes does to feet
The five systems the examination is checking.
Diabetic shoes and inserts
What your risk category means for footwear.
Blisters on a diabetic foot
One of the things a daily check is looking for.
The ICD-10 codes
How the findings above get coded.
Diabetic foot care products
The six items that do almost all the work, and the three sold for diabetic feet that should never touch one.
Book an at-risk foot exam in Michigan
Balance Foot & Ankle performs comprehensive diabetic foot examinations in Howell and Bloomfield Hills, including sensation testing, circulation assessment and a written plan.
Dr. Tom Biernacki is a double board-certified podiatric foot and ankle surgeon practising in Michigan. He treats diabetic wounds, Charcot neuroarthropathy and at-risk feet daily, and writes here to put the clinical reasoning behind that care in front of the people living with it.