Screening

Screening for foot complications in people with diabetes over the age of 12 should be done at least once yearly.[9][24][37]​ The screening examination identifies risk factors and may help reduce the risk of limb loss. The importance of foot care must be emphasised to the patient as part of the annual assessment.[9]

See Diagnosis approach (Physical examination) for more information on how to perform a foot examination in a person with diabetes.

In the UK, the National Institute for Health and Care Excellence (NICE) recommends assessing the risk of foot problems in adults with diabetes:[9] 

  • At the 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]

NICE recommends stratifying the person's risk of developing a diabetic foot problem using the following classification.[9]

  • Low risk: no risk factors present except callus alone.

  • Moderate risk: one or more of deformity, neuropathy, or peripheral arterial disease.

  • High risk: one or more of previous ulceration; previous amputation; on renal replacement therapy; neuropathy and non-critical limb ischaemia together; neuropathy in combination with callus and/or deformity; or non-critical limb ischaemia in combination with callus and/or deformity.

  • Active diabetic foot problem: one or more of ulceration; infection; chronic limb-threatening ischaemia; gangrene; or suspicion of an acute Charcot neuro-osteoarthropathy, or an unexplained hot, swollen foot with a change in colour, with or without pain.

Refer any patient who is at moderate or high risk to a specialist foot protection service; in the UK, NICE recommends that any patient at high risk must be seen within 2-4 weeks and any patient at moderate risk must be seen within 6-8 weeks.[9] Foot reassessments should be carried out annually for those at low risk, every 3-6 months for those at moderate risk, and at least every 1-2 months for those at high risk.[9]

See Management approach (Prevention) for more information on the recommended frequency of foot checks following risk stratification.

The American Diabetes Association (ADA) also recommends screening for foot complications in patients with diabetes at least once yearly.[37][51]​ At-risk individuals should be assessed at each visit and should be referred to foot care specialists for ongoing preventive care and surveillance.

The IWGDF has developed a risk stratification system for assessing a patient’s risk of developing foot ulcers, which is also recommended by the ADA.[24][37][51] The frequency of foot checks can be determined based on this system, which groups people into risk categories from 0 to 4: 

Category 0 (very low risk):

  • No loss of protective sensation (LOPS) and no peripheral arterial disease (PAD):

Annual foot screening and examination

Category 1 (low risk):

  • LOPS or PAD

Foot screening and examination once every 6-12 months

Category 2 (moderate risk):

  • LOPS + PAD, or

  • LOPS + foot deformity, or

  • PAD + foot deformity

Foot screening and examination once every 3-6 months

Category 3 (high risk):

  • LOPS or PAD, and one or more of the following:

    • History of a foot ulcer

    • A lower extremity amputation (minor or major)

    • End-stage renal disease

Foot screening and examination once every 1-3 months

LOPS is defined as a reduction in sensation or proprioception, as assessed using a 10-g monofilament, the Ipswich Touch Test, tuning fork or biothesiometer/neurothesiometer.

The IWGDF definition of ‘foot deformity’ includes any limitation in foot or ankle movement. See History and exam for the full list of deformities.

Patients with diabetic foot ulcers are at especially high risk of malnutrition. It is recommended that healthcare providers develop and implement a formalised nutrition screening and assessment protocol to help identify patients with or at risk of malnutrition. A number of validated screening tools are available; for example, Nutritional Risk Index (NRI), Malnutrition Universal Screening Tool (MUST), and Mini Nutritional Assessment (MNA).[52] ​Choice of screening tool depends on the population and available resources. If initial screening suggests an increased risk for malnutrition, the next step should be a thorough nutrition assessment; for example, Patient-Centered Subjective Global Assessment (PC-SGA) or Nutrition Focused Physical Assessment (NFPA).[52]

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