Diabetic foot complications remain one of the most significant and costly consequences of diabetes worldwide. Peripheral neuropathy, particularly the loss of protective sensation (LOPS), is a major risk factor for foot ulceration, infection, and eventual amputation. Early identification of neuropathy is therefore essential for prevention. Among the various screening tools available, the Ipswich Touch Test (IpTT) has emerged as a simple, rapid, and effective method for detecting sensory loss in the diabetic foot. Developed by Gerry Rayman and colleagues at Ipswich Hospital in the UK, the test was designed to address gaps in inpatient foot screening and to reduce preventable ulceration. This essay explores the development, methodology, evidence base, advantages, limitations, and clinical significance of the IpTT in diabetic foot care.
Background: The Need for Simple Neuropathy Screening
Peripheral neuropathy affects up to half of individuals with long?standing diabetes. Loss of protective sensation increases the risk of unnoticed trauma, pressure injury, and subsequent ulceration. Standard screening tools such as the 10?g monofilament, tuning fork, or biothesiometer are effective but require equipment, training, and time — resources that may not always be available in busy clinical environments or inpatient wards.
Rayman and colleagues observed that many inpatients with diabetes were not receiving adequate foot checks, leading to preventable heel ulcers and other complications. This gap inspired the development of the Ipswich Touch Test as a no?equipment, easy?to?teach, easy?to?perform screening method that could be implemented widely and consistently.
Methodology of the Ipswich Touch Test
The IpTT is intentionally simple. According to Physiopedia and PodiaPaedia, the test involves lightly touching the tips of the first, third, and fifth toes on each foot — six sites in total — using the examiner’s index finger for 1–2 seconds. The patient closes their eyes and responds “yes” when they feel the touch. Importantly:
- The examiner must not press, poke, or tap, as this may stimulate deep pressure rather than light touch.
- Each toe is touched only once.
- A score of 6/6 indicates normal sensation.
- A score of <4/6 suggests neuropathy and loss of protective sensation.
This simplicity allows the test to be performed by clinicians, nurses, healthcare assistants, or even trained family members.
Evidence for Validity and Reliability
Multiple studies have evaluated the IpTT’s accuracy and reproducibility. Rayman et al.’s original research demonstrated substantial inter?operator reproducibility, with a kappa value of 0.68, indicating good agreement between examiners. This is particularly important for a screening tool intended for use by staff with varying levels of clinical experience.
A systematic review and meta?analysis published in BMJ Open further supported the test’s validity. Zhao et al. found that the IpTT had good sensitivity and specificity for detecting diabetic peripheral neuropathy, making it a reliable alternative when monofilaments are unavailable. The review highlighted the test’s potential for widespread use in both inpatient and outpatient settings.
Additional validation comes from studies such as Fithri et al. (2025), which confirmed the IpTT’s effectiveness in screening for loss of protective sensation in individuals with type II diabetes. These findings reinforce the test’s utility as a practical, evidence?based tool.
Advantages of the Ipswich Touch Test
1. No Equipment Required
The IpTT’s greatest strength is its simplicity. Unlike monofilaments, which can bend, degrade, or be misplaced, the IpTT requires only a clinician’s finger. This makes it ideal for:
- Inpatient wards
- Emergency departments
- Low?resource settings
- Home visits
- Community screening programs
2. Rapid and Easy to Teach
The test takes less than a minute to perform and can be taught quickly to healthcare staff. This ease of use supports consistent screening, even in busy clinical environments.
3. Cost?Effective
Because it requires no equipment, the IpTT is essentially cost?free. This is particularly valuable in health systems with limited budgets or in regions where monofilaments are not readily available.
4. Evidence?Based
Studies consistently show that the IpTT performs comparably to the 10?g monofilament in detecting neuropathy. Its reproducibility and diagnostic accuracy make it a credible screening tool.
5. Improves Inpatient Foot Care
Rayman’s team developed the test specifically to address poor inpatient foot screening. Implementation at Ipswich Hospital led to a significant reduction in heel ulcers, demonstrating real?world impact.
Limitations of the Ipswich Touch Test
Despite its strengths, the IpTT is not without limitations.
1. Subjectivity
The test relies on patient responses, which may be influenced by:
- Cognitive impairment
- Communication difficulties
- Anxiety or inattention
2. Less Standardized Than Monofilament Testing
While monofilaments apply a consistent 10?g force, finger pressure varies between examiners. Although the test requires only light touch, variability is inevitable.
3. Not a Diagnostic Tool
The IpTT is a screening method. Abnormal results should prompt further assessment using validated diagnostic tools such as:
- 10?g monofilament
- Vibration perception threshold testing
- Nerve conduction studies
4. Limited Sensory Modalities
The test assesses only light touch. Neuropathy is multifaceted, involving:
- Vibration sense
- Temperature discrimination
- Proprioception
Thus, the IpTT should be part of a broader foot assessment.
Clinical Significance and Integration into Practice
The IpTT aligns with global recommendations for routine diabetic foot screening. Its simplicity makes it particularly valuable in settings where traditional tools are unavailable or underused. In inpatient environments, where foot checks are often overlooked, the IpTT can serve as a quick, reliable method to identify at?risk patients and trigger protective interventions such as:
- Pressure offloading
- Heel protection
- Podiatry referral
- Patient education
In community and primary care settings, the IpTT can complement annual foot examinations, ensuring that neuropathy is detected early and managed proactively.
The Ipswich Touch Test represents an elegant solution to a widespread clinical challenge: how to ensure consistent, effective screening for diabetic peripheral neuropathy across diverse healthcare settings. Developed to address gaps in inpatient foot care, the IpTT has proven to be a valid, reliable, and highly practical tool. Its no?equipment design, ease of use, and strong evidence base make it an invaluable addition to diabetic foot assessment.
While it does not replace more comprehensive diagnostic tools, the IpTT fills a critical niche by enabling rapid identification of patients at risk of foot ulceration. As diabetes prevalence continues to rise globally, simple and scalable interventions like the Ipswich Touch Test will play an essential role in reducing preventable complications and improving patient outcomes.