Primary prevention
Regular foot checks by healthcare professionals are essential for the prevention of diabetes-related foot disease. The American Diabetes Association (ADA) recommends a regular, comprehensive foot exam in all patients with diabetes mellitus to identify risk factors that are predictive of ulcers and amputations: this should be done at least annually, and more frequently in higher-risk patients.[22]
See Diagnosis approach (Physical exam) 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, and the recommended frequency of foot checks.
At-risk patients should be encouraged to examine their feet on a daily basis. 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 neighbors for frequent visual inspections.[22]
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.[23] People with an IWGDF score of 0 (very low risk) should be screened and examined annually, but otherwise do not need any specific interventions to prevent foot complications.[23] For those with an IWGDF score of 1-3 (low, moderate, and high risk), the following primary prevention measures are recommended:[23][38]
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 nonrigid 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)
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).[23] 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 4.0°F (2.2°C) 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.[23]
Considerations for comorbidities and risk factors
Optimal care of patients should include management of cardiovascular risk factors to within recommended treatment goals. This includes:[22][39]
Glucose 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).[22]
The table that follows summarizes recommendations for primary prevention of foot ulcers in people with diabetes taken from the International Working Group on the Diabetic Foot (IWGDF) Guidelines on the prevention and management of diabetes-related foot disease.[23]
Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Adult with type 1 or type 2 diabetes at very low risk of foot ulceration (IWGDF risk 0)
Patients with no loss of protective sensation (LOPS) and no peripheral arterial disease (PAD)
All
Intervention
Foot screening
Foot screening should be performed by an adequately trained healthcare professional. It should include:
Assessment for presence of a foot ulcer, excess callus, or pre-ulcerative lesions (e.g., blisters, fissures, or hemorrhage)
Neurological assessment (10-gram monofilament testing or Ipswich touch test)
Vascular assessment (including pedal pulses)
If monofilament testing does not show LOPS, test for limited vibratory sensation with a tuning fork or biothesiometer/neurothesiometer.
If PAD is suspected, consider referral for pedal Doppler waveforms in combination with ankle-brachial index (ABI) and toe-brachial index (TBI).
Goal
Identify the at-risk foot; prevent diabetes-related foot disease
Foot screening should be performed once every 12 months for people at very low risk of foot ulceration.
Adult with type 1 or type 2 diabetes at low risk of foot ulceration (IWGDF risk 1)
Patients with LOPS or PAD
All
Intervention
Perform a foot examination; provide structured education on foot self-care and footwear; consider referral to foot-ankle exercise program; suggest an increase in weight-bearing daily activity
Foot examination should be performed by an adequately trained healthcare professional. It should include:
A detailed history asking about foot ulceration or lower-extremity amputation; end-stage renal disease; presence of social isolation, poor access to healthcare, or financial constraints; depression or similar psychological comorbidities; frailty; foot pain (with walking or at rest); numbness or claudication; physical limitations that may hinder foot self-care (e.g., visual acuity, obesity)
Assessment for presence of a foot ulcer, excess callus, or pre-ulcerative lesions (e.g., blisters, fissures, or hemorrhage)
Neurological assessment (10-g monofilament testing or Ipswich touch test)
Vascular assessment (including pedal pulses)
Assessment of foot deformity
Assessment of foot and ankle joint mobility
Check for abnormal skin color, temperature, or edema
Assessment of foot hygiene
If monofilament testing does not show LOPS, test for limited vibratory sensation with a tuning fork or biothesiometer/neurothesiometer.
If previously undiagnosed PAD is suspected, consider referral for pedal Doppler waveforms in combination with ABI and TBI.
For people with LOPS, an appropriately trained professional should evaluate footwear fit with the person in the standing position, preferably at the end of the day.
Provide structured foot care education. This should include information about:
Foot ulcers and their consequences
Adequate foot protection (e.g., no walking barefoot or in socks without shoes, and avoid thin soled slippers and open type footwear)
Proper foot hygiene (e.g., wash feet daily - but avoid soaking feet in a bath -and dry carefully, particularly between the toes; use emollients; cut toenails straight across)
Importance of daily foot inspection and rapid contact with an appropriately trained healthcare professional if the patient has any concerns about (pre-)ulcerative lesions
Wearing footwear that accommodates the shape of the feet and fits properly, and seamless socks made of natural materials in a light color so that stains from (pre-)ulcerative lesions are visible
Checking the inside of the shoe for any foreign objects each time before putting on footwear
Be aware of cultural considerations around footwear and the impact this may have on uptake of wearing appropriate footwear and the level of education and support that will be required for uptake.
Structured education should be appropriate to personal circumstances, feasible, and accessible. It can take many forms, for example verbal education, pictorial education, education integrated into motivational interviewing, video education, booklets, software applications, and quizzes. The education should be provided by a healthcare professional with disease-specific knowledge and skills in education. It may be 1:1 or in small groups, and should be over several sessions with periodical reinforcement to maximize effect.
Consider referral to an 8-12-week foot-ankle exercise program (including stretching, strengthening, and functional exercises), preferably supervised by a physical therapist. Patients should undergo a foot assessment and exercise prescription prior to commencing exercise, and progress should be evaluated weekly with modification of the program as required. Advise continuing foot-ankle exercises after the program has ended.
Consider communicating that gradually increasing walking-related weight-bearing daily activity is likely to be safe regarding risk of foot ulceration. Advise wearing appropriate footwear when undertaking weight-bearing activities, to avoid sudden spikes in activity, and to frequently monitor the skin for pre-ulcerative lesions or breakdown.
Goal
Prevent or delay diabetes-related foot disease
Foot examination should be performed every 6-12 months for people at low risk.
In a person with LOPS, it is not required to repeat the assessment of LOPS at subsequent examinations.
Individual factors (e.g., lack of adherence with adequate footwear in someone with LOPS) should be considered when determining the right preventative treatments/interval between foot examinations for the individual person.
Goals of education aimed at preventing diabetic-related foot disease include:
Improving foot care knowledge
Improving self-care behavior
Encouraging adherence to the foot self-care education provided
Encourage and remind patients about foot self-care at all subsequent visits.
The goal of a foot and ankle exercise program is to improve foot and ankle joint range of motion, neuropathy signs and symptoms, and plantar pressure distribution (without increasing the risk of ulceration).
The goal of a gradual increase in walking-related weight-bearing daily activity is to increase daily steps by a maximum of 10% per week to an end goal of an additional 1000 steps/day compared to baseline. This has been shown to be beneficial for glycemic control in people with diabetes.
With pre-ulcerative lesion, excess callus on the foot, ingrown toenails, or fungal infections on the foot
Intervention
Provide immediate treatment
Treatment by an appropriately trained healthcare professional may include:
Removing excess callus
Protecting and draining blisters
Treating fissures
Treating ingrown or thickened toenails
Treating cutaneous hemorrhage
Prescribing antifungal treatment for fungal infections.
Goal
Prevent a foot ulcer
With nonrigid hammertoe with nail changes, excess callus or a pre-ulcerative lesion on the apex or distal part of this toe
Intervention
Consider digital flexor tendon tenotomy; consider prescribing orthotic interventions
Consider flexor tenotomy if a pre-ulcerative lesion on the toe fails to respond to nonsurgical treatment and normalization of the foot structure is required to prevent ulceration.
To reduce excess callus and the associated increased foot pressure, toe silicone and (semi-)rigid orthoses or felted foam can be prescribed in addition to therapeutic footwear. Provide information on proper use of the orthosis to avoid wrong placement.
Goal
Prevent a first or recurrent foot ulcer; reduce excess callus on the toe
Adult with type 1 or type 2 diabetes at medium risk of foot ulceration (IWGDF risk 2)
Patients with LOPS and PAD; or LOPS and foot deformity; or PAD and foot deformity
All
Intervention
Provide integrated foot care; consider coaching to self-monitor foot skin temperatures; consider referral to foot-ankle exercise program; suggest an increase in weight-bearing daily activity
Provide integrated foot care including as a minimum: foot examination, professional foot care, adequate footwear, and structured education about self-care.
Foot examination should be performed by an adequately trained healthcare professional. It should include:
A detailed history asking about foot ulceration or lower-extremity amputation; end-stage renal disease; presence of social isolation, poor access to healthcare, or financial constraints; depression or similar psychological comorbidities; frailty; foot pain (with walking or at rest); numbness or claudication; physical limitations that may hinder foot self-care (e.g., visual acuity, obesity)
Assessment for presence of a foot ulcer, excess callus, or pre-ulcerative lesions (e.g., blisters, fissures, or hemorrhage)
Neurological assessment (10-g monofilament testing or Ipswich touch test)
Vascular assessment (including pedal pulses)
Assessment of foot deformity
Assessment of foot and ankle joint mobility
Check for abnormal skin color, temperature or edema
Assessment of foot hygiene
If monofilament testing does not show LOPS, test for limited vibratory sensation with a tuning fork or biothesiometer/neurothesiometer.
If previously undiagnosed PAD is suspected, consider referral for pedal Doppler waveforms in combination with ABI and TBI.
For people with LOPS, an appropriately trained professional should evaluate footwear fit with the person in the standing position, preferably at the end of the day.
Provide structured foot care education. This should include information about:
Foot ulcers and their consequences
Adequate foot protection (e.g., no walking barefoot or in socks without shoes, and avoid thin soled slippers and open type footwear)
Proper foot hygiene (e.g., wash feet daily -but avoid soaking feet in a bath - and dry carefully, particularly between the toes; use emollients; cut toenails straight across)
Importance of daily foot inspection and rapid contact with an appropriately trained healthcare professional if any concerns about (pre-)ulcerative lesions
Wearing footwear that accommodates the shape of the feet and fits properly, and seamless socks made of natural materials in a light color so that stains from (pre-)ulcerative lesions are visible
Checking the inside of the shoe for any foreign objects each time before putting on footwear
Be aware of cultural considerations around footwear and the impact this may have on uptake of wearing appropriate footwear and the level of education and support that will be required for uptake.
Structured education should be appropriate to personal circumstances, feasible, and accessible. It can take many forms, for example verbal education, pictorial education, education integrated into motivational interviewing, video education, booklets, software applications, and quizzes. The education should be provided by a healthcare professional with disease-specific knowledge and skills in education. It may be 1:1 or in small groups, and should be over several sessions with periodical reinforcement to maximize effect.
Consider coaching to self-monitor plantar foot skin temperatures using an infrared thermometer once a day to identify any early signs of foot inflammation.
Consider referral to an 8-12-week foot-ankle exercise program (including stretching, strengthening, and functional exercises), preferably supervised by a physical therapist. Patients should undergo a foot assessment and exercise prescription prior to commencing exercise, and progress should be evaluated weekly with modification of the program as required. Advise continuing foot-ankle exercises after the program has ended.
Consider communicating that gradually increasing walking-related weight-bearing daily activity is likely to be safe regarding risk of foot ulceration. Advise wearing appropriate footwear when undertaking weight-bearing activities, to avoid sudden spikes in activity, and to frequently monitor the skin for pre-ulcerative lesions or breakdown.
Goal
Prevent or delay diabetes-related foot disease
Repeat integrated foot care, or reevaluate the need for it, once every 3-6 months for people at medium risk.
In a person with LOPS, it is not required to repeat the assessment of LOPS at subsequent examinations.
Individual factors (e.g., lack of adherence with adequate footwear in someone with LOPS) should be considered when determining the right preventative treatments/interval between foot examinations for the individual person.
Goals of education aimed at preventing diabetic-related foot disease include:
Improving foot care knowledge
Improving self-care behavior
Encouraging adherence to the foot self-care education provided
Encourage and remind patients about foot self-care at all subsequent visits.
Self-monitoring foot temperature: if the temperature difference between corresponding regions of the left and right foot is >4.0 °F (2.2 °C) on 2 consecutive days, ambulatory activity should be reduced and the patient should consult an adequately trained healthcare professional for further diagnosis and treatment.
The goal of a foot and ankle exercise program is to improve foot and ankle joint range of motion, neuropathy signs and symptoms and plantar pressure distribution (without increasing the risk of ulceration).
The goal of a gradual increase in walking-related weight-bearing daily activity is to increase daily steps by a maximum of 10% per week to an end goal of an additional 1000 steps/day compared to baseline. This has been shown to be beneficial for glycemic control in people with diabetes.
With a foot deformity that significantly increases pressure or a pre-ulcerative lesion
Intervention
Consider prescribing extra-depth shoes, custom-made footwear, custom-made insoles, and/or toe orthoses
Goal
Change foot biomechanics and reduce plantar pressure on at-risk locations to prevent or delay diabetes-related foot disease
With pre-ulcerative lesion, excess callus on the foot, ingrown toenails, or fungal infections on the foot
Intervention
Provide immediate treatment
Treatment by an appropriately trained healthcare professional may include:
Removing excess callus
Protecting and draining blisters
Treating fissures
Treating ingrown or thickened toenails
Treating cutaneous hemorrhage
Prescribing antifungal treatment for fungal infections
Goal
Prevent a foot ulcer
With nonrigid hammertoe with nail changes, excess callus, or a pre-ulcerative lesion on the apex or distal part of this toe
Intervention
Consider digital flexor tendon tenotomy; consider prescribing orthotic interventions
Consider flexor tenotomy if a pre-ulcerative lesion on the toe fails to respond to nonsurgical treatment and normalization of the foot structure is required to prevent ulceration.
To reduce excess callus and the associated increased foot pressure, toe silicone and (semi-)rigid orthoses or felted foam can be prescribed in addition to therapeutic footwear. Provide information on proper use of the orthosis to avoid wrong placement.
Goal
Prevent a first or recurrent foot ulcer; reduce excess callus on the toe
Adult with type 1 or type 2 diabetes at high risk of foot ulceration (IWGDF risk 3)
Patients with LOPS or PAD, and one or more of: history of a foot ulcer, a lower extremity amputation (minor or major), end-stage renal disease
All
Intervention
Provide integrated foot care; consider coaching to self-monitor foot skin temperatures
Provide integrated foot care including as a minimum: foot examination, professional foot care, adequate footwear, and structured education about self-care.
Foot examination should be performed by an adequately trained healthcare professional. It should include:
A detailed history asking about foot ulceration or lower-extremity amputation; end-stage renal disease; presence of social isolation, poor access to healthcare, or financial constraints; depression or similar psychological comorbidities; frailty; foot pain (with walking or at rest); numbness or claudication; physical limitations that may hinder foot self-care (e.g., visual acuity, obesity)
Assessment for presence of a foot ulcer, excess callus, or pre-ulcerative lesions (e.g., blisters, fissures, or hemorrhage)
Neurological assessment (10-g monofilament testing or Ipswich touch test)
Vascular assessment (including pedal pulses)
Assessment of foot deformity
Assessment of foot and ankle joint mobility
Check for abnormal skin color, temperature or edema
Assessment of foot hygiene
If monofilament testing does not show LOPS, test for limited vibratory sensation with a tuning fork or biothesiometer/neurothesiometer.
If previously undiagnosed PAD is suspected, consider referral for pedal Doppler waveforms in combination with ABI and TBI.
For people with LOPS, an appropriately trained professional should evaluate footwear fit with the person in the standing position, preferably at the end of the day.
Provide structured foot care education. This should include information about:
Foot ulcers and their consequences
Adequate foot protection (e.g., no walking barefoot or in socks without shoes, and avoid thin soled slippers and open type footwear)
Proper foot hygiene (e.g., wash feet daily -but avoid soaking feet in a bath - and dry carefully, particularly between the toes; use emollients; cut toenails straight across)
Importance of daily foot inspection and rapid contact with an appropriately trained healthcare professional if any concerns about (pre-)ulcerative lesions
Wearing footwear that accommodates the shape of the feet and fits properly, and seamless socks made of natural materials in a light color so that stains from (pre-)ulcerative lesions are visible
Checking the inside of the shoe for any foreign objects each time before putting on footwear
Be aware of cultural considerations around footwear and the impact this may have on uptake of wearing appropriate footwear and the level of education and support that will be required for uptake.
Structured education should be appropriate to personal circumstances, feasible, and accessible. It can take many forms, for example verbal education, pictorial education, education integrated into motivational interviewing, video education, booklets, software applications, and quizzes. The education should be provided by a healthcare professional with disease-specific knowledge and skills in education. It may be 1:1 or in small groups, and should be over several sessions with periodical reinforcement to maximize effect.
Consider coaching to self-monitor plantar foot skin temperatures using an infrared thermometer once a day to identify any early signs of foot inflammation.
Goal
Prevent or delay diabetes-related foot disease
Repeat integrated foot care, or reevaluate the need for it, once every 1-3 months for people at high risk.
In a person with LOPS, it is not required to repeat the assessment of LOPS at subsequent examinations.
Individual factors (e.g., lack of adherence with adequate footwear in someone with LOPS) should be considered when determining the right preventative treatments/interval between foot examinations for the individual person.
Goals of education aimed at preventing diabetic-related foot disease include:
Improving foot care knowledge
Improving self-care behavior
Encouraging adherence to the foot self-care education provided
Encourage and remind patients about foot self-care at all subsequent visits.
Self-monitoring foot temperature: if the temperature difference between corresponding regions of the left and right foot is >4.0 °F (>2.2 °C) on 2 consecutive days, ambulatory activity should be reduced and the patient should consult an adequately trained healthcare professional for further diagnosis and treatment.
With a foot deformity that significantly increases pressure or a pre-ulcerative lesion
Intervention
Consider prescribing extra-depth shoes, custom-made footwear, custom-made insoles, and/or toe orthoses
Goal
Change foot biomechanics and reduce plantar pressure on at-risk locations to prevent or delay diabetes-related foot disease
With a healed plantar foot ulcer
Intervention
Prescribe therapeutic footwear
The footwear prescribed needs to have demonstrated plantar pressure-relieving effect during walking.
Encourage consistent wear of the prescribed footwear, both indoors and outdoors.
Goal
Prevent a recurrent plantar foot ulcer
At high pressure locations there should be a ≥30% reduction in the in-shoe peak pressure during walking, or an in-shoe peak pressure <200kPa.
With pre-ulcerative lesion, excess callus on the foot, ingrown toenails, or fungal infections on the foot
Intervention
Provide immediate treatment
Treatment by an appropriately trained healthcare professional may include:
Removing excess callus
Protecting and draining blisters
Treating fissures
Treating ingrown or thickened toenails
Treating cutaneous hemorrhage
Prescribing antifungal treatment for fungal infections
Goal
Prevent a foot ulcer
With nonrigid hammertoe with nail changes, excess callus, or a pre-ulcerative lesion on the apex or distal part of this toe
Intervention
Consider digital flexor tendon tenotomy; consider prescribing orthotic interventions
Consider flexor tenotomy if a pre-ulcerative lesion on the toe fails to respond to nonsurgical treatment and normalization of the foot structure is required to prevent ulceration.
To reduce excess callus and the associated increased foot pressure, toe silicone and (semi-)rigid orthoses or felted foam can be prescribed in addition to therapeutic footwear. Provide information on proper use of the orthosis to avoid wrong placement.
Goal
Prevent a first or recurrent foot ulcer; reduce excess callus on the toe
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.[6]
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.[23] 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 primary prevention, above, including referral to an integrated foot care program.
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.[23]
Surveillance duplex ultrasound exams may be important in optimizing the long-term patency of surgical bypasses. Patients should be made aware of the institutional schedule of these exams.
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 glycemic control, blood pressure control, lipid control, and smoking cessation.[22][121]
In those with peripheral arterial disease, management with pharmacotherapy (antiplatelets, statins) should be optimised with revascularization as needed.[121]
In patients with end-stage renal disease receiving renal replacement therapy, feet should be protected during the hemodialysis session (e.g., offloading with protective boot).[77] Foot checks should also be carried out regularly during hemodialysis sessions.[77]
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