The physical examination must include the systemic examination, limb examination, skin examination, and ulcer examination. The systemic examination must evaluate the heart thoroughly as primary pathology may be in the heart. Also all the systems must be examined as respiratory, cardiac, neurological, abdomen, musculoskeletal examination.

In the examination of the limb, especially palpate all the pulses up to dorsalis pedis, assess capillary filling time, and also look for signs of venous hypertension. These signs include varicose veins and pigmentation of the skin over the lower leg. The diameter of the limb at various levels must be measured including the normal side also. Mobility should also be assessed at all joints. Leg range of motion at the ankle/knee/hip should also be assessed to distinguish between pain from inflammation and pain from arterial insufficiency. One must examine the sensation of the foot along with motor power.

Always examine the surrounding tissue. Venous disease may present with staining and pigmented spots especially around the ankle, brawny skin, lipodermatosclerosis, reticular or varicose veins, atrophic blanche (patchy areas of ischemia), telangiectasia, and stasis eczema. In venous ulcers, the surrounding skin may be erythematous with scaling, irregular shaggy borders, and crusting. On the other hand, patients with arterial disease have trophic changes of chronic ischemia, with pale skin which is often hairless, cool, and shiny. Nails may be thickened nail and architecture of the foot may be deformed.

For having a firm diagnosis, location and pain are the key findings. Venous leg ulcers usually occur in the gaiter region of the lower leg, most often medially, and are superficial with poorly defined margins. The floor is usually red granulation tissue with moderate to high levels of exudate. Exudate levels vary depending on the ulcer size, the presence of leg edema, and the presence or absence of infection. Obese patients with coexisting lymphedema may have more edema and more exudates. Arterial ulcers can occur anywhere on the lower leg and less likely in the gaiter region. Many arterial/ischemic ulcers occur over a bony prominence and have a history of pressure related to the cause. Arterial ulcers have slough and devitalized tissue in the wound floor and less wound exudate. In patients with ulcers on the sole of the foot, the sole should be examined for signs of ascending infection, including proximal tenderness and appearance of pus on proximal compression of the sole. Surrounding calluses are typical of neuropathic ulcerations, and sinus track formation should be explored by probing the wounds. Neuropathic ulcers especially in diabetic patients and other neurological problems occur on the sole of the feet under the metatarsal heads, in the area with the most postural pressure exerted. The other types of ulcers may occur in any part of the lower extremity. The degree of discomfort or pain can give clue to the underlying condition. Arterial ulcers are particularly painful at night, can become severe, and are relieved by dependency and made worse by elevation, even to a horizontal position in bed. Venous ulcers are mildly painful, relieved with elevation, and often get relief from a gentle massaging of the surrounding skin. Ulcers with signs of inflammation with a purple border and extreme pain may be because of vasculitis or underlying connective tissue disorder. They often present with a rapid increase in size, severe pain, and necrotic tissue in the wound base. Lesions that present as blisters such as bullous pemphigoid are related to an autoimmune condition [5]. Table 6.2 shows the differential diagnosis of common ulcers.