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David G. Armstrong, DPM; Lawrence A. Lavery, DPM, MPH; Steven A. Vela; Terri L. Quebedeaux, DPM; John G. Fleischli, DPM

Arch Intern Med. 1998;158:289-292.

Objective  To evaluate the sensitivity and specificity of 3 sensory perception testing instruments to screen for risk of diabetic foot ulceration.

Methods  This case-control study prospectively measured the degree of peripheral sensory neuropathy in diabetic patients with and without foot ulcers. We enrolled 115 age-matched diabetic patients (40% male) with a case-control ratio of approximately 1:3 (30 cases and 85 controls) from a tertiary care diabetic foot specialty clinic. Cases were defined as individuals who had an existing foot ulceration or a history of a recently (<4 weeks) healed foot ulceration. Controls were defined as subjects with no foot ulceration history. Using receiver operating characteristic analysis, we evaluated the sensitivity and specificity of 2 commonly used neuropathy assessment tools (vibration perception threshold testing and the Semmes-Weinstein 10-g monofilament wire system) and a 4-question verbal neuropathy score to evaluate for presence of foot ulceration.

Results  A vibration perception threshold test using 25 V and lack of perception at 4 or more sites using the Semmes-Weinstein 10-g monofilament wire system had a significantly higher specificity than the neuropathy score used. The neuropathy score was most sensitive when 1 or more answers were affirmative. When modalities were combined, particularly the monofilament wire system plus vibration perception threshold testing and the neuropathy score plus the monofilament wire system, there was a substantial increase in specificity with little or no diminution in sensitivity.

Conclusions  The early detection of peripheral neuropathy or loss of "protective sensation" is paramount to instituting a structured treatment plan to prevent lower extremity amputation. The results of our study suggest that all 3 sensory perception testing instruments are sensitive in identifying patients at risk for ulceration. Combining modalities appears to increase specificity with very little or no diminution in sensitivity.

From the Department of Orthopaedics, University of Texas Health Science Center (Drs Armstrong, Lavery, Quebedeaux, and Fleischli and Mr Vela), The Diabetic Foot Research Group (Drs Armstrong, Lavery, and Fleischli), and the Mexican American Medical Treatment Effectiveness Research Center (Dr Lavery), San Antonio, Tex.

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