Identifying Patients With Diabetes Mellitus Who Are

at Risk for Lower-Extremity Complications: Use of

Semmes-Weinstein Monofilaments
Michael J Mueller
PHYS THER. 1996; 76:68-71.

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 Identifying Patients With Diabetes
Mellitus Who Are at Risk for Lower-
Extremity Complications: Use of
Semmes-Weinstein Monofilaments
lantar ulcers and lower-extremity amputation are frequent, severe, and
costly problems in patien& with diabetes mellitus (DM) .I Although there
are many risk factors for developing foot problems, peripheral n e u r e
pathy is an important factor that seems to predispose patients to plantar
ulcers and a m p u t a t i ~ n . ~

Patients with DM and peripheral neuropathy typically show a gradual loss of

sensation o n the plantar surface of their feet in a stocking-glove pattern.' They
seem to reach a threshold of insensitivity that puts them a t risk for developing
unnoticed ulcers on the plantar surface of the foot. This threshold has been
referred to as the level of "protective sensation."? Clinicians need a method of
easily and reliably testing for protective sensation to identify patients who are at
risk for foot problems. Identification of those patients may allow preventive
intervention.

Studies have indicated that Semmes-Weinstein (SW) monofilaments can be an

effective, reliable, and useful tool for identifying patients with DM who are at risk
for foot problems.

Description of SW Monofilaments
Semmes-Weinstein monofilaments are calibrated nylon monofilaments (Figure).
Monofilaments generate a reproducible buckling stress and are identified by
mani~facturer-assigned numbers that range from 1.65 to 6.65. The higher the
value of the monofilament, the stiffer and more difficult it is to bend, according
to the formula: nominal value = log,,,[force (in milligrams) X lo].* Three
monofilaments commonly used to screen patients at risk for peripheral neuro-
pathy are the 4.17, the 5.07, and the 6.10.:3.4Forces required to bend these
monofilaments are 1, 10, and 75 g of force, respectively."

Key Words: Ankk and foot, Diabetes, Peripheral nmropathy, Ulcers.

[Muellel- MJ. Identifying patients with diabetes nlellitus who are
at risk for lower-extremity complications: use of Semmes-
Weinstein monofilaments. Phys ?'her. 1996;76:68-71.1

Michael J Mueller

68 Physical Therapy . Volume 76 . Number 1 . January 1996

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 Clinicians need a
method of easily
The monofilaments can be used to measure the patient's and reliably testing of foot deformity, and a his-
ability to sense a point of pressure. The rationale for testing tory of lower-extremity ulcer-
the ability of a patient to sense pressure is that repeated for protective ation or amputation. Over a
bouts of moderate amounts of unnoticed pressures are 32-month prospective pe-
thought to be the primary mechanism for development of sensation to riod, 41 of the 358 patients
plantar ulcers in patients with DM and peripheral developed ulcers and 14
identify patients
nei~ropathy.~ patients underwent a lower-
who are at risk for extremity amputation. In-
Ability to Determine Levels of Protective Sensation sensitivity to the 5.07 SW
Birke and Sims%ere the first to define the level of protective foot problems. monofilament occurred in
sensation using 4.17, 5.07, and 6.10 monofilaments in a 19% of the patients screen-
group of 72 patients with Hansen's disease and 28 patients ed. Among this group, the odds ratio of subsequent ulcer-
with DM.:i The lowest threshold of pressure sensation in ation was 9.9 and the odds ratio of amputation was 17
patients with a history of an ulcer was SW monofilarnent 6.10. compared with the odds ratios among those who retained
No patient with a neuropathic ulcer was able to sense the sensation.
5.07 monofilarnent. The authors concluded that the 5.07
monofilament was the best indicator of protective ~ensation.:~ Preliminary results from another prospective study also
Other s t u d i e ~ , ~all
- ~ retrospective, have confirmed these support use of the 5.07 SW monofilament as a screening tool.
results. Boyko e t all1 are following 778 subjects with DM in an
internal medicine outpatient clinic. They report having
Sosenko et a1"sed 17 different monofilaments and con- observed 88 foot ulcers and 20 lower-extremity amputations
cluded that the 4.21 monofilament was the threshold that over a cumulative 1,375 person-years of follow-up. Inability
best discriminated between patients with and without foot to sense the 5.07 SW monofilament was an independent
ulcers. The 4.21 monofilament lies between the 4.17 and the predictor for higher risk of foot ulceration (odds
5.07 monofilaments reported in the other studies and may ratio=18.42).I1 These prospective s t u d i e ~ , along~ ~ ~ , with
~~
represent a more specific level of protective sensation. retrospective s t u d i e ~ , : ~provide
-~ considerable evidence to
Additional studies are needed to verify this level. support the use of the 5.07 SW monofilament as a valid
predictor of patients at risk for foot problems.
Rith-Najarian et all0 conducted a prospective evaluation of
simple screening criteria, which included the 5.07 SW mono- Methods for Testing With SW Monofilaments
filament. Patients with DM in a well-defined American All studies agreed that the SW n~onofilamentsare easy to use.
Indian population were stratified into risk categories based In general, the patient is instructed to lie supine in a quiet
on ability to sense the 5.07 SW monofilament, the presence area. Subjects are blindfolded or told to close their eyes to

"Research Designs Inc, 7320 Ahhcroft, Houston, TX 77081.

M.J Mueller, PhD, PT, is Assistant Professor, Program in Physical Therapy, Washington University School o f Medicine,
Box 8.50'2, 4444 Forest Park Blvd, St Louis, MO 631 10 (USA) (muellerm@n~edicine.wustl.edu).

This work was supported in part by a grant (ROl-HD :1148&01) fiom the National Institutes of Health,
National (:enter for Meclical Rehabilitation Research.

Physical Therapy . Volume 76 . Number 1 . January 1996 Mueller . 69

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Figure.
Use of a Semmes-Weinstein monofilament to test pressure sensation in a
patient with diabetes mellitus and foot
eliminate visual input. The filament is applied perpendicular
to the skin (Figure) with enough force to cause the mono-
filament to buckle for approximately 1 second."
Sensory testing with SW monofilaments can be applied to
any anatomical region, but when used as a screen for risk of
foot ulcers, testing usually is performed in those regions at
highest risk for skin breakdown. Those regions on the
plantar surface of the foot at highest risk for skin breakdown
are the metatarsal heads and the great t ~ e . " ~Mueller
, ~ ~ ) e t a14
70 . Mueller
Downloaded from http://ptjournal.apta.org/ by guest on January 19, 2015
tested the first, third, and fifth metatarsal heads and toes; the
medial and lateral midfoot; and the heel. Holewski et a15 also
advised testing the dorsal surface of the foot between the
base of the first and second toes, the base of the third digit,
and the base of the fifth metatarsal. Their rationale was that,
in addition to testing the function of the plantar nerves, use
of these sites provides a representation of different periph-
eral nerves and dermatomes of the foot."
Patient Instruction
Two methods of patient instruction have been described.
The "yes-no" method instructs the patient to say "yes" each
time he or she senses the application of a SW monofila-
ment."4,1z Five to 10 trials are to be taken at each site, and
the patient needs to respond to 80% of the trials to be
graded a given value at that site. If the patient is unable to
sense at least 80% of the trials, he or she is tested with the
next highest monofilament. Using this method, Birke and
Sims3 reported reliability "at the 95% confidence interval."
Diamond et all2 reported Kappa values for intrarater and
interrater reliability ranging from .72 to .83.
Other auth0r9.~,"1~) reported using a "forced-choice" proce-
dure. Using this procedure, the monofilament is applied to
each testing site during only one of two time intervals, with
the count of either "one" or "two." The patient is asked
whether he o r she felt any sensation after the first o r second
interval, but the patient is allowed to report that he or she
could not determine the interval during which the stimulus
was applied.Wolewski et a15 argued that this method forces
the patient to choose when the stimulus was applied during
one of the two possible intervals, eliminating the need for
the patient to decide when a stimulus was sufficiently above
the background level to justify a response. The authors tested
a group of patients three times and found that the responses
agreed in 89% of the trial^.^ Gerr and Letzl" compared thq
yes-no method with the forced-choice method when using a
test of peripheral cutaneous vibration sensitivity. They con-
cluded that the yes-no method was more reliable and less
time consuming than the forced-choice method.'"
Criteria for Determining Level o f Protective Sensation
Authors have differed slightly in their criteria for determin-
ing protective sensation. The more conservative approach
advocates that the foot be considered "at risk" if any portion
of the foot is insensitive to the 5.07 m o n ~ f i l a m e n t . : ' ~ ~ ~ ~
Others5 have suggested that three of six sites should be
insensitive to the 5.07 monofilament to be considered "at
risk." The one completed prospective study that identified a
strong correlation between ability to sense the 5.07 SW
monofilament and foot problems graded the foot as "insen-
sitive" if one o r more areas failed to sense the monofila-
ment.1° These results are strong evidence to support the
more conservative approach.
Physical Therapy . Volume 76 . Number 1 . January 1996
Authors have agreed that testing with SW monofilaments is
inexpensive and easy when compared with other quantitative
tests of sensation. Studies"-" have demonstrated that SW
morlofilament testing is as effective as or superior to more
time-consuming tests of vibration, temperature, and pero-
neal nerve current perception in identifying patients at risk
for ulceration.
5 HolewskiJ, Stress RM. Graf PM. Grunfeld <;. Aesthesiometry: quantifica-
tion of cutaneous pressure sensation in diabetic peripheral neuropathy.
,/Kthn/nl KPS Dm. 1Y88;25:1-1 0.
6 Kumar S, Fernando DJS, Veves A, etal. Semmes-Weinstein monofila-
ments: a simple, effective and inexpensive screening device for identifying
diabetic patients at risk of foot ulceration. Diabeles h . 7 Clin Prart. 1995;13:
63-68.

7 01mos PR, Cataland S, O'Dorisio TM, et al. The SetnmesWeinstein

Limitations of This Review
Other methods are available to indicate the presence of
peripheral neuropathies, and many factors other than
peripheral neuropathy may contribute to foot problems in
patients with DM. The focus of this update, however, is to
review the use of SW monofilaments in measuring pressure
sensation to screen patients at risk for foot problems. The
interested reiader is referred to other references that provide
a thorough overview of the factors that can contribute to foot
disease in patients with diabetes and appropriate assessment
and management strategies for this patient p o p ~ l a t i o n . ~ . ' ~ .high
Summary
Research indicates that the SW monofilament is an inexpen-
sive, reliable, valid, and easy-to-use clinical indicator for
identifying patients who are at risk for developing foot ulcers
and subsequent amputations. Those patients unable to sense
the 5.07 SW monofilament on any part of their foot should
be provided preventive care, including patient education
and prescription of appropriate therapeutic footwear.
References
1 Most RS, Sinnock P. The epidemiology of lower-extremity amputation in
diabetic individ~ials.Diabr1t.c (hrt. 1983;6:87-9 1.
2 Bild DE, Selby J V , Sinnock P, et al. Lower-extremity amputation in people
with diabetes: epidemiology and prevention. Diabttt.r Cart. 1989;12:24-31.
3 Birke JA, Sims DS. Plantar sensory threshold in the Hansen's disease
ulcerative foot. Read at the Proceedings of the International Conference on
Biomechanics and <:linical Kinesiology of Hand and Foot; Madras, India;
December 16-1 8, 1985.
monofilament as a potential predictor of foot ulceration in patients with
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8 McNeely MJ, Boyko EJ, Ahroni JH, et al. The independent cont~~butions
of diabetic neuropathy and vasculopathy in foot ulceration: How great are
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sensory-threshold measures for their association with foot ulceraticln in
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4 Mueller hfJ, Diamond JE, Delitto A, Sinacore DR. Insensitivity, limited

joint mobility. :and plantar ulcers in patients with diabetes niellitus. Pt~ys
7hrr. 1989;69:4!5.% 462.

Physical Therapy. Volume 76 . Number 1 . January 1996 Mueller . 71

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 Identifying Patients With Diabetes Mellitus Who Are
at Risk for Lower-Extremity Complications: Use of
Semmes-Weinstein Monofilaments
Michael J Mueller
PHYS THER. 1996; 76:68-71.

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