Comprehensive Diabetic Foot Care Recommendations
All individuals with diabetes should receive a comprehensive foot evaluation at least annually, with more frequent examinations for those with risk factors, to prevent ulcers and amputations. 1
Risk Assessment and Examination Frequency
Risk Stratification
The International Working Group on Diabetic Foot risk stratification system provides clear guidance on examination frequency 1:
| Risk Category | Characteristics | Examination Frequency |
|---|---|---|
| Very Low | No LOPS and no PAD | Annually |
| Low | LOPS or PAD | Every 6-12 months |
| Moderate | LOPS + PAD, or LOPS + foot deformity, or PAD + foot deformity | Every 3-6 months |
| High | LOPS or PAD and history of foot ulcer, amputation, or end-stage renal disease | Every 1-3 months |
Comprehensive Foot Examination Components
Every foot examination should include 1:
- Inspection of skin integrity
- Assessment of foot deformities
- Neurological assessment (10-g monofilament testing plus at least one other: pinprick, temperature, or vibration)
- Vascular assessment including pulses in legs and feet
- Prior history of ulceration, amputation, Charcot foot, vascular surgery
- Assessment of current symptoms
Patient Education for Foot Self-Care
All patients with diabetes should be educated on 1, 2:
- Daily foot inspection, including between toes
- Regular washing with careful drying, especially between toes
- Water temperature always below 37°C (98.6°F)
- Avoiding barefoot walking indoors or outdoors
- Not using heaters or hot-water bottles to warm feet
- Avoiding chemical agents or plasters to remove corns/calluses
- Daily inspection of shoes for foreign objects
- Not wearing tight shoes or shoes with rough edges
- Using lubricating oils/creams for dry skin (not between toes)
- Daily change of socks
- Wearing seamless socks or with seams inside out
- Cutting nails straight across
- Seeking professional care for corns and calluses
Footwear Recommendations
Appropriate footwear is crucial for preventing foot complications 1, 2:
- Specialized therapeutic footwear is recommended for high-risk patients
- Shoes should be 1-2 cm longer than the foot
- Internal width should equal foot width at metatarsal phalangeal joints
- Adequate height to allow room for toes
- Evaluate fit with patient standing, preferably at end of day
- Break in new shoes gradually to minimize blisters and ulcers
- Custom-molded shoes may be needed for extreme deformities
Special Considerations for High-Risk Patients
For patients with high-risk conditions 1, 2:
- Interprofessional approach with podiatrist and other specialists
- Immediate referral for any new lesions, discoloration, or pain
- Regular callus debridement to reduce pressure points
- Smoking cessation to reduce vascular disease complications
- Visual assistance if patient has visual impairment
Treatment of Diabetic Foot Ulcers
When ulcers develop despite preventive care 1:
- Prompt treatment is essential to prevent complications
- For chronic ulcers that fail to heal with standard care, consider adjunctive treatments:
- Negative-pressure wound therapy
- Placental membranes
- Bioengineered skin substitutes
- Acellular matrices
- Autologous fibrin and leukocyte platelet patches
- Topical oxygen therapy
Common Pitfalls to Avoid
- Inadequate footwear selection (standard shoes are insufficient for high-risk patients) 2
- Focusing only on ulcer sites while neglecting the entire foot 2
- Neglecting patient education on daily foot care 3
- Delayed treatment of pre-ulcerative signs like calluses 2
- Overlooking the importance of glycemic control in preventing neuropathy 1
- Failing to recognize that asymptomatic patients may still have serious foot problems 1
Diabetic foot complications represent major causes of morbidity and mortality, but with proper assessment, education, and preventive care, many of these complications can be prevented or managed effectively. The cornerstone of prevention is regular examination, appropriate footwear, and comprehensive patient education.