How to Do a Level-Three Foot Screening

Printer-Friendly Level-Three Foot Screening Form (PDF-47 KB)

Diabetic Neuropathy is a degenerative disease of the peripheral nerves and a common complication of diabetes. Autonomic, sensory and motor functions may be affected individually or in combination with varying degrees of severity. This nerve damage can create conditions in the foot that produce secondary problems such as deformity and foot ulceration, which may lead to amputation. It is our hope to minimize or eliminate the devastating effects of peripheral neuropathy through careful monitoring of the feet using a foot screen, patient education and appropriate referral to a foot care specialist when needed.

Three levels of screening exist for the diabetic foot depending on the level of expertise of the individual performing the evaluation.

The Level Three Leap Foot Screen requires advanced knowledge of foot biomechanics and is usually performed by a physician or physical therapist. It is designed to evaluate Range of Motion/Strength, Sensation, Skin Condition, Nerve Status, Vision, Mobility, Deformity and Vascular Status resulting in patient placement into a Risk Category that dictates the follow-up and treatment regime.

Foot Evaluation

Date ___/___/______

Name __________________________ ID # ___________


DM Type I or Type II on Insulin , Oral Agents , None

Other Dx: _____________________________________________

HX Foot Ulcer Y_ N_, Surgery Y_ N_

Employed Y_ N_, or Homemaker Y_ N_, Student Y_ N_

Activity Sitting ___% vs Standing/Walking ___%

Indep Amb__ , W/AmbAids__ , SBA__ , Assist__ , WC__

Ambulation Distance: Unlimited__ , Limited Community__ ,

Homebound__ , Non-ambulatory__

Exercise Y_ N_; H-Impact , L-Impact__ , # __ days/wk

Other __________________________________________________


Rt. ROM Rt. MMT   Lt. MMT Lt.ROM
    Ankle Dorsiflexion    
    Ankle Plantarflexion    
    Ankle Inversion    
    Ankle Eversion    
    Great Toe Extension    
    Great Toe Flexion    
    Intrinsics (graded 0-2)    


Sensory Level: 1 = 1gm, 2 = 10gm, 3 = 75gm, 4 = > 75gm


Label: D = dryness, S = swelling, R = redness, T = temperature

M = maceration, C = callus P = pre-ulcer U = ulcer


Right   Left
Y_ N_ Dorsal Pedal Pulse Y_ N_
Y_ N_ Posterior Tibial Pulse Y_ N_
Y_ N_ Shiny, hairless, atrophic skin Y_ N_
Y_ N_ Capillary refill < 3 sec Y_ N_

Other _____________________________________


Right   Left
  Hammer / Claw Toes  
  Bunion / Bony Prominence  
  Planus / Cavus  
  Hallux Limitus  
  Rear/Forefoot Varus  
  PF 1st Ray/Forefoot Valgus  
  Dorsiflexed First Ray  
  Equinus /Calcaneus  
  Drop Foot  
  Charcot Fracture  
  Partial Foot Amputation  


Right   Left
Y_ N_ Able to Identify a Foot Mark Y_ N_


Standard Y_ N_
Prescription Y_ N_

Describe: __________________________

Appropriate Y_ N_
Worn Y_ N_


1. Foot Injury Risk

__0 - No loss of protective sensation

__1 - Loss of protective sensation

__2 - Loss of protective sensation and high pressure (callus or deformity) and/or poor circulation

__3 – History or foot ulcer or Charcot fracture

2. _______________________________________

3. _______________________________________

Plan /Goals

Instruct in self care/ Independent foot inspection footwear selection appropriate foot care __

Fit and train in Crutches Walker__ / Independent NWB PWB gait __

Evaluate Orthotic Footwear Prosthesis__ / Proper fit and prevent tissue injury __

Instruct in Exercises / increase ROM increase Strength__ general conditioning __

Fabricate foot orthoses shoe modification__ / Prevent tissue injury __

Fabricate a Relief Pad Healing shoe Contact Cast Walking Splint __/ Off-load pressure __

Debride wound__ / clean wound and promote healing __

Other ________________________________________

Frequency/Duration _____________________________

Signature _____________________________________

Screening for loss of protective sensation (LOPS) is the key step in the LEAP Program.

Using the 5.07/10 gram monofilament, the clinician tests 4 plantar sites on each foot (8 sites total) and indicates a positive or negative response for each site tested. A negative response at any site identifies LOPS and considers this patient at high risk for plantar ulceration.

If the patient has a LOPS but no history of plantar ulceration, follw up and re-evaluation of the foot should accur at least twice a year. In addition, protective footwear must be worn at all times and the patient is discouraged from going barefoot. A soft custom insole is recommended for all of the patient's footwear and shower sandals are encouraged.

The vulnerability of the foot when protective sensation is absent should not be taken lightly and education of the patient on the risks of ulceration should be stressed.

Date Last Reviewed:  April 2017

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More Information on LEAP

LEAP Foot Screen (PDF - 222 KB)

Patient Education (PDF - 1.92 MB)

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