South West Regional Wound Care Toolkit

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1 B. 2. INTERDISCIPLINARY LOWER LEG ASSESSMENT 2.1 Purpose and Instructions for the Lower leg Assessment Tool Purpose This tool is to assist the nurse in assessment of the lower leg and in particular, to identify and document any abnormality of the lower leg and contains recommendations for actions based on abnormal findings. Instructions Please include the individual s demographics at the top right hand corner of the tool, either with an identifier sticker/addressograph or by printing the information in by hand. Sections a-l: This is to be used by a qualified health care professional (see Competency Levels in Introduction to Toolkit) to do a thorough assessment of the lower leg when an ulcer is present and/or when peripheral or arterial issues are noted. Sections m- p: A Wound Care Specialist is required to complete. While a Wound Care Specialist nurse may not diagnose, they can assess characteristics to allow them to request further investigations in order for the physician to form a definitive diagnosis. Please note: Patient permission was received to use all photos contained in this document for educational purposes. a. Ulcer or pre-ulcerous conditions Please add the history of previous ulcer(s) and date of onset of the new ulcer(s)/pre-ulcerous condition(s). If there are numerous sites, please list. Use the tick boxes to identify characteristics of the ulcer and surrounding skin. b. Pain (specific to legs) Check off the box that identifies the type of pain the patient is experiencing. If pain is uncontrolled use the tick box to indicate that you are requesting or referring to pain specialist to address control. Pain occurs in as much as 76% of venous ulcers. Deep ulcers, particularly those around the malleolus, or small ulcers surrounded by atrophie blanche are the most painful.. SWRWC Toolkit B.2.1 Lower Leg Assessment: Purpose and Instructions_July-10_2011 1

c. Foot Deformities, Nails and Footwear Use the check boxes to check off all those that apply when examining the foot Foot Deformities Description Hammer toes - in a hammertoe deformity, the first

Assessment & Management of Foot Ulcers for People with Diabetes. Toronto, Canada: Registered Nurses Association of Ontario.

It is not painful at first, but when the toes deviate even more, redness, swelling and pain at or near the joint occur.

2 c. Foot Deformities, Nails and Footwear Use the check boxes to check off all those that apply when examining the foot Foot Deformities Description Hammer toes - in a hammertoe deformity, the first joint (MTP) is cocked upward, and the middle joint (PIP) bends downward. Examples Illustration used with permission of artist Nancy Bauer and the Registered Nurses Association of Ontario (2005). Assessment & Management of Foot Ulcers for People with Diabetes. Toronto, Canada: Registered Nurses Association of Ontario. Hallux valgus (bunion deformity) occurs when the great toe begins to deviate, developing a firm bump on the inside edge of the foot. It is not painful at first, but when the toes deviate even more, redness, swelling and pain at or near the joint occur. The pain is caused by pressure of the footwear on the bunion or from the pressure inside the joint. Hallux valgus describes the change in position of the toe, and bunion describes the bump on the foot. Illustration used with permission of artist Nancy Bauer and the Registered Nurses Association of Ontario (2005). Assessment & Management of Foot Ulcers for People with Diabetes. Toronto, Canada: Registered Nurses Association of Ontario. Halgus Valgus or Small Bunion(Mild/Moderate) joint at the base of big toeis pushed to the side Hallus Valgus or Large Bunion (Severe) big toe may move under second toe Fixed ankle joint- Fibrous or bony ankylosis at the ankle can occur because of immobility (joint assumes the least painful position and becomes fixed). In venous insufficiency, fibrotic tissue deposits due to lipodermatosclerosis also decrease ankle mobility lose ability to dorsiflex. This decreases the chance of healing by 70%. No illustration available SWRWC Toolkit B.2.1 Lower Leg Assessment: Purpose and Instructions_July-10_2011 2

Claw toes - A claw toe deformity has a cocked up MTP joint, and both the middle joint (PIP) and the tiny joint at the end of the toe (the DIP) are curled downward like a claw.

Toronto, Canada: Registered Nurses Association of Ontario.

Dropped arch- Pes Planus also called fallen arches or flat foot Drawing used with permission of artist Nancy Bauer and the RNAO (2005).

Claw Toe No illustration available Pes Planus Dropped MTH Pes Cavus the arch is abnormally high, with the forefoot extended below. The toes are often clawed.

Walking on this without proper protection causes more damage to the foot structure. In advances state, the sole of the foot forms a rocker shape, increasing the risk of ulceration.

3 Claw toes - A claw toe deformity has a cocked up MTP joint, and both the middle joint (PIP) and the tiny joint at the end of the toe (the DIP) are curled downward like a claw. Illustration used with permission of artist Nancy Bauer and the Registered Nurses Association of Ontario (2005). Assessment & Management of Foot Ulcers for People with Diabetes. Toronto, Canada: Registered Nurses Association of Ontario. Hallus rigidus caused by osteoarthritis in the MTP joint at the base of the big toe, causing pain and loss of motion in the MTP joint. Dropped arch- Pes Planus also called fallen arches or flat foot Drawing used with permission of artist Nancy Bauer and the RNAO (2005). Assessment & Management of Foot Ulcers for People with Diabetes. Toronto, Canada: Registered Nurses Association of Ontario. Claw Toe No illustration available Pes Planus Dropped MTH Pes Cavus the arch is abnormally high, with the forefoot extended below. The toes are often clawed. Illustration used with permission of artist Nancy Bauer and the Registered Nurses Association of Ontario (2005). Assessment & Management of Foot Ulcers for People with Diabetes. Toronto, Canada: Registered Nurses Association of Ontario. Charcot Joint- a form of neuroarthropathy. Nerve damage causes the ligaments and muscles to atrophy, which causes joint instability. Walking on this without proper protection causes more damage to the foot structure. In advances state, the sole of the foot forms a rocker shape, increasing the risk of ulceration. Illustration used with permission of artist Nancy Bauer and the Registered Nurses Association of Ontario (2005). Assessment & Management of Foot Ulcers for People with Diabetes. Toronto, Canada: Registered Nurses Association of Ontario. Charcot Arthropathy Pes Cavus SWRWC Toolkit B.2.1 Lower Leg Assessment: Purpose and Instructions_July-10_2011 3

Corns - A corn is thickened skin on the top or side of a toe, usually from shoes that do not fit properly.

Example of corn with ulceration: Calluses- A callus is thickened skin on your the soles of the feet, caused when there is foot deformity

Sensory neuropathy eliminates the protective painful signal caused by tissue damage while motor neuropathy leads to muscle atrophy, foot

The increased local plantar pressure and trauma is associated with callus formation that usually precedes skin breakdown.

Fissures these commonly occur on the heels, but can develop elsewhere on the foot if there is thickened hyperkeratotic skin caused by dryness,

These can pose a serious risk as they can be a pathway for bacteria and infection.

4 Corns - A corn is thickened skin on the top or side of a toe, usually from shoes that do not fit properly. Corns may cause discomfort, while calluses normally do not. Example of corn with ulceration: Calluses- A callus is thickened skin on your the soles of the feet, caused when there is foot deformity secondary to neuropathy or other causes. Sensory neuropathy eliminates the protective painful signal caused by tissue damage while motor neuropathy leads to muscle atrophy, foot deformity, altered biomechanics, and increased plantar pressure. The increased local plantar pressure and trauma is associated with callus formation that usually precedes skin breakdown. Without callus debridement and pressure relief the persons with diabetes develop chronic non-healing ulceration. Fissures these commonly occur on the heels, but can develop elsewhere on the foot if there is thickened hyperkeratotic skin caused by dryness, walking barefoot or wearing sandals or open-backed shoes or from inactive sweat glands caused by neuropathy. These can pose a serious risk as they can be a pathway for bacteria and infection. Examples: Footwear Assessment: Orthotics not being worn at all times, indoor or out: the purpose of orthotics is to help distribute pressure away from the areas of higher pressure. If they are not worn at all times, the benefit is significantly reduced. It is important to redistribute plantar pressure with the use of various walking devices and footwear. This step is critical for the prevention of pressure build up and callus formation by cushioning, accommodating, realigning, stabilizing, and unloading rigid or deformed structures. SWRWC Toolkit B.2.1 Lower Leg Assessment: Purpose and Instructions_July-10_2011 4

Inappropriate footwear- e.g. high-heeled or narrow-toed shoes may cause pressure areas. If the toes are squeezed or pinched together, the bony prominences of the toes can cause pressure ulcers.

The filament is pressed against part of the foot. When the filament bends, its tip is exerting a pressure of 10 grams (therefore this monofilament is often referred to as the 10 gram monofilament).

5 Inappropriate footwear- e.g. high-heeled or narrow-toed shoes may cause pressure areas. If the toes are squeezed or pinched together, the bony prominences of the toes can cause pressure ulcers. Presence of pressure areas: document any areas of redness d. Test for Neuropathy To test for neuropathies use a monofilament (available at The filament is pressed against part of the foot. When the filament bends, its tip is exerting a pressure of 10 grams (therefore this monofilament is often referred to as the 10 gram monofilament). If the patient cannot feel the monofilament at certain specified sites on the foot, he/she has lost enough sensation to be at risk of developing a neuropathic ulcer. Please refer to the diagram in the tool for the 10 pressure points to test. Score is out of ten. Please check off any other sensory and motor findings. Please refer to a foot specialist if there is a loss of protective sensation and refer to an OT if underlying pressure and/or surface concerns. e. DIABETIC FOOT RISK CLASSIFICATION SYSTEM: The International Working Group Original and Modified Criteria 2010 Use the International Working Group on the Diabetic Foot Risk Classification System: Modified Criteria 2010 Indicate the level of risk that you have identified based on your findings. f. The University of Texas Staging System for Diabetic Foot Ulcers (only for clients with Diabetic Foot Ulcer) Describe the Stage and Grade of the ulcer based on the descriptors in the chart. g. Edema (if present) Check off all areas affected. Pitting edema can be demonstrated by applying pressure to the swollen area by depressing the skin with a finger x seconds. If the pressing causes an indentation that persists for some time after the release of the pressure, the edema is referred to as pitting edema. It is graded based on the depth of the indentation: 1+ = 0 - ¼ 2+ = ¼ ½ 3+ = ½ = takes several minutes to rebound SWRWC Toolkit B.2.1 Lower Leg Assessment: Purpose and Instructions_July-10_2011 5

In non-pitting edema, pressure that is applied to the skin does not result in a persistent indentation.

Brawny Induration - Brawny means swollen and hardened, while induration is abnormal firmness of tissues with margins. Palpate where it starts and stops.

LYMPHEDEMA ASSESSMENT *NB- individuals can have symptoms of both venous disease & lymphedema or lymphedema & lipedema Check off all areas affected- descriptors are present in the tool. i. LIPEDEMA ASSESSMENT *NB- individuals can have symptoms of both lymphedema & lipedema Check off all areas affected- descriptors are present in the tool.

6 In non-pitting edema, pressure that is applied to the skin does not result in a persistent indentation. Non-pitting edema can occur in certain disorders of the lymphatic system such as lymphedema, where edema is particularly prominent on the dorsum of the feet and in the toes. Brawny Induration - Brawny means swollen and hardened, while induration is abnormal firmness of tissues with margins. Palpate where it starts and stops. Induration results in an inability to pinch the tissues. h. LYMPHEDEMA ASSESSMENT *NB- individuals can have symptoms of both venous disease & lymphedema or lymphedema & lipedema Check off all areas affected- descriptors are present in the tool. i. LIPEDEMA ASSESSMENT *NB- individuals can have symptoms of both lymphedema & lipedema Check off all areas affected- descriptors are present in the tool. j. Skin & Anatomy Check off all venous and arterial signs and symptoms observed. Signs of arterial disease will warrant further investigation of peripheral arterial status. Signs and Symptoms of Venous Disease: Check off all areas affected- descriptors are present in the tool. Descriptors Examples Varicosities- either small or larger vessels SWRWC Toolkit B.2.1 Lower Leg Assessment: Purpose and Instructions_July-10_2011 6

Hemosiderin staining- Brown or brownish red pigmentation and purpura caused by

lower 1/3 of leg becomes sclerotic and woody.

heal. Acute lipodermatosclerosis- This presents as a painful and tender condition

It represents a panniculitis associated with venous insufficiency.

Photograph used with permission of Dr. V. Falanga.

may develop cellulitis through breaks in the skin.

plaques. Ulcerations tend to be exquisitely painful.

7 Hemosiderin staining- Brown or brownish red pigmentation and purpura caused by extravasation of red blood cells into the dermis Chronic Lipodermatosclerosis- lower 1/3 of leg becomes sclerotic and woody. Leg becomes champagne bottle or bowlingpin shaped ulcers are more difficult to heal. Acute lipodermatosclerosis- This presents as a painful and tender condition of the leg. It is frequently misdiagnosed as cellulitis or morphea. It represents a panniculitis associated with venous insufficiency. Ulcers can occur within the lesion, which becomes intensely fibrotic over time. Photograph used with permission of Dr. V. Falanga. Stasis or venous dermatitis - erythema, scaling, pruritis, and sometimes weeping- may develop cellulitis through breaks in the skin. Atrophie blanche - Located on the ankle or foot, ivory white lesions, atrophic plaques. Ulcerations tend to be exquisitely painful. The white lesions represent scarring from previous injuries. Woody fibrosis - deposits of fibrin in the deep dermis and fat results in a woody induration of the gaiter area of the leg SWRWC Toolkit B.2.1 Lower Leg Assessment: Purpose and Instructions_July-10_2011 7

Ankle (submalleolar) flare - Incompetence in

hypertension and causes dilation of the venules

slough/ fibrin Ulcer located in gaiter region (lower

lower leg superior to malleolus but can be on

Ulcerations may encircle the entire ankle; ulcers

Scarring from previous ulcer(s)- evidence of

Arterial Disease: Descriptors Hairless little or no

thin and fragile and pale in colour Shiny skin on

8 Ankle (submalleolar) flare - Incompetence in perforating vein valve which results in venous hypertension and causes dilation of the venules Ulcer base moist with granulation &/or yellow slough/ fibrin Ulcer located in gaiter region (lower 1/3 of calf) - Ulceration usually on the medial lower leg superior to malleolus but can be on lateral aspect as well. Ulcerations may encircle the entire ankle; ulcers occurring above mid-calf or on the foot likely have other origins. Ulcer located superior to the medial malleolus Scarring from previous ulcer(s)- evidence of previous ulcerations noted Signs and Symptoms of Arterial Disease: Descriptors Hairless little or no hair on the lower legs or feet Thin- skin appears thin and fragile and pale in colour Shiny skin on legs and feet Examples No illustration available No illustration available No illustration available SWRWC Toolkit B.2.1 Lower Leg Assessment: Purpose and Instructions_July-10_2011 8

Dependent rubor occurs in the presence of arterial compromise and can mimic cellulitis. The rubor disappears when the foot is elevated, which would not happen with cellulitis.

Blanching on elevation -- occurs in the presence of arterial compromise and represents decrease in arterial flow without the gravitational effect of having the foot below the level

(Gangrene also present) No illustration available Toes cool/cold/blue- in this photograph, the 4 th toe is becoming ischemic secondary to infection.

9 Dependent rubor occurs in the presence of arterial compromise and can mimic cellulitis. The rubor disappears when the foot is elevated, which would not happen with cellulitis. It can be bilateral. Blanching on elevation -- occurs in the presence of arterial compromise and represents decrease in arterial flow without the gravitational effect of having the foot below the level of the heart. It can be bilateral. (Gangrene also present) Feet cool/cold/blue this occurs in the presence of arterial disease, often just involving one leg or foot in comparison to the other. (Gangrene also present) No illustration available Toes cool/cold/blue- in this photograph, the 4 th toe is becoming ischemic secondary to infection. Lower temperature in one leg compared to other one leg feels cooler than the corresponding area on the other leg this generally suggests the presence of PAD in the cooler leg, but can also be from increased temperature in a leg with infection or cellulitis. No illustration available SWRWC Toolkit B.2.1 Lower Leg Assessment: Purpose and Instructions_July-10_2011 9

Capillary refill time: > 3 seconds Delayed capillary refill time (CFT) is suggestive of peripheral arterial disease. Normal CFT is less than 3 seconds.

com Ulcer located on foot or toes - often on the heels, tips of toes, between the toes where the toes rub against one another or anywhere the bones may protrude

aspx Ulcer base pale and dry &/or contains eschar the ulcer may initially have grey or purplish tissue that bleeds very little and will turn to eschar if

Ulcer round and punched out in appearance arterial ulcers do not usually have irregular edges and the edges do not slope gently down to the wound bed Gangrene

10 Capillary refill time: > 3 seconds Delayed capillary refill time (CFT) is suggestive of peripheral arterial disease. Normal CFT is less than 3 seconds. Photographs used with permission of myfootshop.com Ulcer located on foot or toes - often on the heels, tips of toes, between the toes where the toes rub against one another or anywhere the bones may protrude and rub against bed sheets, socks or shoes. Definition from : Ulcer base pale and dry &/or contains eschar the ulcer may initially have grey or purplish tissue that bleeds very little and will turn to eschar if allowed to dry out. Ulcer round and punched out in appearance arterial ulcers do not usually have irregular edges and the edges do not slope gently down to the wound bed Gangrene dry/wet Dry gangrene (ischemia) may start out red in colour and cool to touch, then turn blue or brownish and then becomes black and will dessicate if allowed to dry. Wet gangrene (infection causing ischemia) starts out with swelling and putrifies, may have foul smelling exudate, fever. Definition from: %20Symptoms SWRWC Toolkit B.2.1 Lower Leg Assessment: Purpose and Instructions_July-10_

Dry & stable gangrene gangrene Wet k. UNUSUAL ULCER The acronym PULL can be used to describe unusual ulcers: P urpura, U ndermining border, L ivedo, unusual L ocation) Dr.

arterial on the lower calf to superior malleolar area. UNUSUAL locations would be any exceptions to this.

If untreated, the disease can persist for months or years, with periods of spontaneous remissions and exacerbations.

11 Dry & stable gangrene gangrene Wet k. UNUSUAL ULCER The acronym PULL can be used to describe unusual ulcers: P urpura, U ndermining border, L ivedo, unusual L ocation) Dr. Vincent Falanga (Canadian Association of Wound Care conference, 2002) Examples of Usual Ulcer locations: Traumatic injuries to the legs often occur in the pre-tibial or calf area as a result of falls or abrasions. Venous ulcers usually occur superior to the medial malleolus, while pressure ulcers appear on bony prominences, diabetic foot ulcers on the plantar foot or toes and arterial ulcers or mixed venous arterial on the lower calf to superior malleolar area. UNUSUAL locations would be any exceptions to this. Examples of unusual leg ulcer appearances Description Bullous Pemphigus- Chronic, autoimmune, subepidermal, blistering skin disease that rarely involves mucous membranes. If untreated, the disease can persist for months or years, with periods of spontaneous remissions and exacerbations. Calciphylaxis- Lesions develop suddenly and progress rapidly; may be singular or many, and they usually occur on the lower extremities; however, may also appear on the hands and torso. There is intense pain, which may require pain specialist interventions. Initially they appear as nonspecific violaceous mottling; as a bluish-red discolouration of the skin with a characteristic network pattern (livedo reticularis) or as erythematous papules, plaques, or nodules. As the disease progresses, more developed lesions have a Examples Early stage new lesions SWRWC Toolkit B.2.1 Lower Leg Assessment: Purpose and Instructions_July-10_

star-like purple coloured configuration with central skin necrosis.

nodules Cutaneous Vasculitis- Often seen associated with palpable purpura, and a

to ulceration which can contain necrotic tissue.

basal cell carcinom and malignant melanoma.

or at the margins of a previously grafted site, and appear as raised or thickened

Squamous cell Marjolin s Ulcer Necrobiosis Lipoidica Diabeticorum -Lesions appear

12 star-like purple coloured configuration with central skin necrosis. Less commonly, lesions may manifest as either bullae or distinct erythematous nodules Cutaneous Vasculitis- Often seen associated with palpable purpura, and a livid erythematous halo, can appear as nodules, bullae or skininfarction, leading to ulceration which can contain necrotic tissue. These are also highly painful and have multiple sites, with unusual shapes and configurations. Older lesions 3 types of malignant wounds can occur on the legs: Squamous cell basal cell carcinom and malignant melanoma. Of these, squamous can occur within a chronic non-healing ulcer (Marjolin s ulcer) or at the margins of a previously grafted site, and appear as raised or thickened edges. Squamous cell Marjolin s Ulcer Necrobiosis Lipoidica Diabeticorum -Lesions appear as well-circumscribed, erythematous plaques, with a depressed, waxy yellow atrophic centre, often in the pre-tibial area. They can also be described as slightly raised shiny red-brown patches occurring on the lower legs. Pyoderma Gangrenosum Lesions are red, tender nodules/ pustules, bluish undermined edges when ulceration occurs; edges may appear motheaten and can be exquisitely painful. l. Circulation: Pulse assessment SWRWC Toolkit B.2.1 Lower Leg Assessment: Purpose and Instructions_July-10_

Check the pulse of the dorsalis pedis, palpable at the prominent arch of the top of the foot between the first and second metatarsal bones. It can be felt in approximately 90% of people.

html Check the pulse of the post-tibial by placing your index finger at the inferior, posterior edge of the medial ankle.

Vascular Assessment including ABPI To be completed by Wound Care Specialist (WCS)/Enterostomal Therapy Nurse (ETN) or in the Vascular/ Diagnostic Imaging Lab Have client avoid smoking or any caffeine

Toe Brachial Pressure Indexes: Calcification of the arteries can occur in people with diabetes, advanced age, longstanding hypertension, or renal disease, and can lead to incompressible arteries in

13 Check the pulse of the dorsalis pedis, palpable at the prominent arch of the top of the foot between the first and second metatarsal bones. It can be felt in approximately 90% of people. Image obtained from Google Images Check the pulse of the post-tibial by placing your index finger at the inferior, posterior edge of the medial ankle. Place your middle and ring finger in a line between this point and the heel of the foot. Image from Google Images m. Vascular Assessment including ABPI To be completed by Wound Care Specialist (WCS)/Enterostomal Therapy Nurse (ETN) or in the Vascular/ Diagnostic Imaging Lab Have client avoid smoking or any caffeine drinks for ½ hour prior to having ABPI or TBPI performed (they can both increase the pressure). n. Toe Brachial Pressure Indexes: Calcification of the arteries can occur in people with diabetes, advanced age, longstanding hypertension, or renal disease, and can lead to incompressible arteries in the ankle. This means that you cannot get a systolic reading when taking the blood pressure in the leg because you cannot obliterate the sound of the pulse. This makes ankle pressures impossible to measure accurately by traditional techniques. Because calcification occurs less commonly in digital arteries, a TBPI is a more reliable indicator of peripheral arterial disease than an ankle brachial index. However, occlusion of the digital artery can occur in the tip of the toe, and would not be apparent when the toe pressure is taking proximal to this. Toe pressures are generally performed in a vascular or diagnostic imaging laboratory with equipment that can show the waveforms (monophasic, biphasic or triphasic) as well as the audible pressures. o. INTERPRETATION OF ABPI &/OR TOE BRACHIAL PRESSURES AND LOWER LEG ASSESSMENT FINDINGS p. Summary Summarize your findings Describe the type of wound Check off the box that describes the wound SWRWC Toolkit B.2.1 Lower Leg Assessment: Purpose and Instructions_July-10_

14 Summarize the Interdisciplinary interventions that are recommended (based on Section B.2, B.3) Literature References : Armstrong, D.G., Lavery, L.A., & Harkless, L.B. (1998). Diabetic Foot Ulcers: Prevention, Diagnosis and Classification American Academy of Family Physicians. March 15, Available at: Accessed Aug. 23, Botros, M., Goettl, K., Parsons, L., Menzildzic, S., Morin, C., Smith, T., Hoar, A., Nesbeth, H., McGrath, & Best, S. (Update: 2010) Practice Recommendations for the Prevention, Diagnosis and Treatment of Diabetic Foot Ulcers: Update Wound Care Canada 8(4): Coutts et al. (2007). RNAO Assessment and Management of Venous Leg Ulcers Guideline supplement. Dissemond, J., Körber,A. & Grabbe, S. Differential diagnosis of leg ulcers Journal der Deutschen Dermatologischen Gesellschaft : Gorst, R. Bagg, G., Albert, M., Shier,B. The Interdisciplinary Lower Leg Assessment Form: The Evolution of a Clinical Assessment Tool Wound Care Canada (3): Available at: Hess, C.T. (2010). Venous ulcer checklist. Advances in Skin and Wound Care. 23(8):384. International Society of Lymphology (ISL) Lymphoedema Staging: (From International Consensus Document Best Practices for the Management of Lymphoedema available at: Moloney, M.C., & Grace, P. Understanding the underlying causes of chronic leg ulceration. JWC 13(6): Patel, K., Grey, J.E., & Harding, K.G. (2006). Abc Of Wound Healing: Uncommon Causes Of Ulceration BMJ: British Medical Journal, Vol. 332, No (Mar. 11, 2006), Peters, E.J.G., & Lavery, L.A. (1998). Effectiveness of the Diabetic Foot Risk Classification System of the International Working Group on the Diabetic Foot. Diabetes Care 21 (5): Vowden, P., & Vowden, K., (2001). Doppler assessment and ABPI: Interpretation in the management of the leg ulceration. Worldwide wounds. Available at: SWRWC Toolkit B.2.1 Lower Leg Assessment: Purpose and Instructions_July-10_

15 Suzuki, K. (2007). How to diagnose Peripheral Arterial Disease. Podiatry Today 20(4) Available at: accessed June 13, 2010 SWRWC Toolkit B.2.1 Lower Leg Assessment: Purpose and Instructions_July-10_

Address: Left Leg. other: Nails: thick yellow brittle fungus abnormal thick yellow brittle fungus abnormal

Address: Left Leg. other: Nails: thick yellow brittle fungus abnormal thick yellow brittle fungus abnormal South West Regional Wound Care Toolkit: Interdisciplinary Lower Leg Assessment Form Instructions for use: Competent/ Proficient/ Expert level HCP to complete if lower leg ulcer present or risk of ulcer