In 166 patients with deep diabetic foot ulcers, a composite clinical diagnosis (clinical assessment plus probe-to-bone test) showed substantial agreement with plain radiography for diabetic foot osteomyelitis, and may serve as a practical adjunct where imaging is unavailable, but it is not a definitive diagnostic test without an independent reference standard.
A composite clinical approach identified osteomyelitis in 117 of 166 patients with deep foot ulcers and excluded it in 49.
Plain radiography was positive in 96 of the 117 composite-positive cases, leaving 21 discordant cases, while all 49 composite-negative cases were radiographically negative.
Compared with plain radiography, the composite clinical approach had 100% sensitivity, 70% specificity and 87.3% overall agreement.
Sensitivity stayed at 100% across ulcer categories, while specificity was higher in SINBAD-5 than SINBAD-4 ulcers.
The authors conclude the composite clinical diagnosis shows substantial agreement with radiography and may be a practical adjunct in resource-limited settings, but is not a definitive test.
Diabetic foot osteomyelitis is a bone infection that can complicate deep foot ulcers in people with diabetes. In places with limited access to imaging, doctors may need to rely on examination and a bedside probe-to-bone test. This study followed 166 patients with deep foot ulcers and compared a combined clinical approach (examination plus probe-to-bone testing) with plain X-rays. The clinical approach flagged 117 patients as having bone infection, and X-rays agreed in 96 of them. All 49 patients cleared by the clinical approach also had negative X-rays. Overall, the two methods agreed in about 87% of patients. The clinical approach missed no X-ray-positive cases, but it labelled some patients as positive whose X-rays were negative, and this was more common in less severe (SINBAD-4) ulcers than in more severe (SINBAD-5) ones. This research suggests that a combined clinical approach could be a useful supporting tool where imaging is hard to get or interpret. However, the comparison was against X-rays rather than bone biopsy, the more definitive test, so the findings show agreement rather than true accuracy. The authors caution that it should not be treated as a definitive diagnostic test.
Abbas Z, Gangji R, Naemi R. (2026). Clinical Diagnosis Versus Plain Radiography for Diabetic Foot Osteomyelitis: A Prospective Study of Diagnostic Agreement in a Resource-Limited Settings.. International wound journal. https://doi.org/10.1111/iwj.71085