Primary prevention
Regular foot checks by healthcare professionals are essential for the prevention of diabetes-related foot disease. In the UK, the National Institute for Health and Care Excellence (NICE) guidelines recommend assessing the risk of foot problems in adults with diabetes:[9]
At time of diagnosis of diabetes, and then at least annually
When any foot problems arise
On any admission to hospital, and if there is any change in the patient's status when in hospital
Patients aged 12-17 years with diabetes should have their feet assessed annually by an appropriately skilled team (in the UK, this should be the paediatric care or transitional care team).[9]
See Diagnosis approach (Physical examination) for more advice on how to perform a foot examination on a person with diabetes. See Screening for more advice on how to stratify a patient’s risk of developing diabetes-related foot disease, including the IWGDF scoring system, and the recommended frequency of foot checks.
The International Working Group on the Diabetic Foot (IWGDF) has produced comprehensive guidelines on the prevention of foot complications in people with diabetes, most recently updated in 2023.[24]
People with an IWGDF score of 0 (very low risk) should be screened and examined annually, but otherwise they do not need any specific interventions to prevent foot complications.[24]
For those with an IWGDF score of 1-3 (low, moderate, and high risk), the following primary prevention measures are recommended:[24][36]
Self-care advice: do not walk barefoot, or in socks without shoes, or in thin-soled slippers, either indoors or outdoors. Wash feet daily with careful drying between toes, apply emollients to dry skin, and cut toenails straight across. Self-examine feet daily and contact a healthcare professional promptly if suspecting any pre-ulcerative lesion.
Provide structured education about appropriate foot self-care to prevent ulceration.
Footwear advice: wear footwear that accommodates the shape of the feet and fits properly. The inside length of the shoe should be 1-2 cm longer than the foot, and should not be too tight or too loose. The internal width should equal the width of the foot at the metatarsal-phalangeal joints or the widest part of the foot), and the height should allow enough room for all the toes. Evaluate the fit with the patient in the standing position, preferably later in the day.
If there is no appropriate off-the-shelf footwear, or if they have an existing foot deformity, consider prescribing therapeutic footwear such as extra-depth shoes, custom-made footwear, insoles and/or toe orthoses.
Prompt treatment of any pre-ulcerative lesions, excess callus, ingrown toenails or fungal infections.
If they have a non-rigid hammertoe with nail changes, excess callus or a pre-ulcerative lesion on the apex or distal part of this toe, consider toe orthotics and/or digital flexor tenotomy.
Consider referral to an 8-12 week foot and ankle exercise program, and/or advising them that walking an extra 1000 steps per day in appropriate footwear is likely to be safe (IWGDF risk 1-2 only).
Referral to an integrated foot care program for ulcer prevention (IWGDF risk 2-3 only).
At-risk patients should be encouraged to examine their feet on a daily basis, according to the ADA.[37] The integrity of the skin on all areas of the foot should be examined for calluses, bunions, blisters, ulcers, or other changes. Socks should be visually inspected before wearing to identify any fabric defects. The inside and outside of shoes should be examined for the integrity of the insole, as well as the presence of any foreign bodies. Patients who cannot see the plantar aspects of their feet because of body shape, poor strength, or poor range of motion can inspect this area by placing a hand mirror on the floor. Those with poor vision should enlist the help of family members or neighbours for frequent visual inspections.[37]
Daily foot thermography has been demonstrated to significantly reduce the risk of developing ulcers in high-risk diabetic feet, and is recommended by the IWGDF for those with a score of 2-3 (moderate and high risk).[24] This consists of using an infrared thermometer to check the cutaneous temperature of the foot for areas which are warmer than surrounding skin. Patients who undertake this type of monitoring should be encouraged to contact their usual footcare team promptly if they notice a persistent temperature difference of more than 2.2°C (4.0°F) on two consecutive days. However, this approach is not widely used at present due to the additional burden it places on patients, limited access to infrared thermometers and a lack of data on cost effectiveness and feasibility.[24]
Considerations for comorbidities and risk factors
Optimal care of patients should include management of cardiovascular risk factors to within recommended treatment goals. This includes:[36][37]
Glycaemic control
Blood pressure control
Lipid control
Smoking cessation
All patients should completely abstain from tobacco use. If this is not feasible, the American Diabetes Association (ADA) recommends referral to a foot care specialist for ongoing preventive care and lifelong surveillance for all patients who smoke and who have additional risk factors for diabetes-related foot disease (e.g., a history of prior lower-extremity complications, loss of protective sensation, structural abnormalities, or peripheral arterial disease).[37]
Peripheral arterial disease
Optimise management with pharmacotherapy (antiplatelets, statins) and revascularisation as needed[38]
End-stage renal disease
Secondary prevention
Close monitoring is essential for people with established diabetic foot problems, as recurrence rates are high: after successful healing of a diabetes-related foot ulcer the recurrence rate is 40% within a year and 65% within 3 years.[21]
As per the IWGDF risk stratification system (see Screening), all patients with existing foot deformities are classed in category 2 (moderate risk of ulceration) and should undergo foot screening and examination once every 3-6 months.[24] All those with a history of a foot ulcer are in category 3 (high risk) and should undergo foot screening and examination once every 1-3 months. These patients should also follow the prevention advice outlined in the Primary prevention section including referral to an integrated foot care programme.
Furthermore, those with a healed plantar foot ulcer should be prescribed therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking, to help prevent a recurrent plantar foot ulcer. Encourage the person to consistently wear this prescribed footwear, both indoors and outdoors.[24]
Offloading devices and surgery can also be considered for the prevention of recurrent ulcers, see Management approach for more information.
Considerations for comorbidities and risk factors
As in primary prevention, management of cardiovascular risk factors is also important for secondary prevention. Considerations include glycaemic control, blood pressure control, lipid control, and smoking cessation.[37][38]
In those with peripheral arterial disease, management with pharmacotherapy (antiplatelets, statins) should be optimised with revascularisation as needed.[38]
In patients with diabetes and end-stage renal disease receiving renal replacement therapy, feet should be protected during the haemodialysis session (e.g., offloading with protective boot).[39] Foot checks should also be carried out regularly during haemodialysis sessions.[39]
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