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Just as surface area measurement can provide information on the rate of wound healing, observation and examination of the periwound skin may provide the clinician with information about circulatory and neurological status. For example, loss of hair over the toes or leg may suggest inadequate perfusion. Similarly, a diminished perception of light touch over the bottom of the foot could indicate that an individual is at risk of developing a plantar ulcer.

This chapter will address various components of the vascular and neurological examinations that may be useful adjuncts in evaluating individuals with ulcerations of the lower extremities. Key aspects of the neurovascular examination such as arterial perfusion, venous patency, valvular competence, and sensory testing will be discussed

Arterial Perfusion

It has been estimated that greater than 12 million people in the United States are affected by peripheral arterial disease (PAD), and more than half of these individuals present asymptomatically or with atypical findings.1,2 Although PAD is discussed in greater detail in Chapter 17, we will look here at a variety of available tests that can provide information about the severity of arterial compromise. Many of these tests are sophisticated and invasive, and others are simple to perform, yet provide valuable clinical information.

The vascular examination should begin with a visual inspection of the extremity, with particular attention being paid to trophic changes. These include the skin taking on a dry, shiny, and hairless appearance. In addition, Assuring may be noted, particularly on the plantar aspect of the feet. Nails also tend to become dystrophic and brittle.


Palpation of extremity pulses is likely one of the simplest, but in some cases the least definitive, methods of assessing peripheral blood flow. Despite this fact, no extremity examination is complete without a peripheral pulse palpation. Not only is the quality of the pulse important, but a comparison between sides can help detect problems that might otherwise go unnoticed.

The lower extremity arteries that should be tested are the iliac, femoral, popliteal, dorsalis pedis, and posterior tibial arteries. It is of note that the popliteal pulse is often more difficult to palpate due to its deeper location behind the knee. Palpation of the popliteal artery is more easily performed with the knee slightly flexed. In addition to noting the presence or absence of a pulse, the quality of the pulse can also be graded as follows:

  • 0 = absence

  • 1+ = pulse barely perceptible

  • 2+ = diminished pulse

  • 3+ = normal pulse

  • 4+ = stronger than normal pulse; possible aneurysm.

It is quite common to find 3+ and 4+ pulses in the distal arteries in individuals with Charcot neuropathy, which is seen in more advanced forms of diabetes. This represents a loss of vasomotor control that results in ...

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