When should a patient be referred for a podiatry consult?

When to Refer for Podiatry Consult

Refer patients with diabetes to podiatry immediately if they have loss of protective sensation (LOPS), prior ulceration or amputation, foot deformities, peripheral arterial disease (PAD), or are on dialysis—these high-risk conditions require specialized foot care to prevent morbidity and mortality from ulceration and amputation. 1

Immediate/Urgent Podiatry Referral

Refer urgently for any of the following:

• Active foot ulceration of any type 1
• History of previous ulceration or amputation (annual ulcer incidence 26% without specialized care) 1, 2
• Charcot foot or unexplained foot swelling, erythema, or warmth 1
• Loss of protective sensation confirmed by inability to feel 10-g monofilament plus one other abnormal test (pinprick, vibration, temperature) 1
• Peripheral arterial disease with symptoms (claudication, rest pain) or absent/decreased pedal pulses 1
• Patients on dialysis (extremely high amputation risk) 1
• Severe foot deformities (bunions, hammertoes) that cannot be accommodated with standard footwear 1

Routine Podiatry Referral for Ongoing Surveillance

Refer for regular preventive care and lifelong surveillance if patient has:

• Smoking history combined with any lower-extremity complication, LOPS, structural abnormality, or PAD 1
• Structural foot abnormalities (even without current ulceration) 1
• Visual impairment preventing adequate self-foot examination 1
• Preulcerative callus or corn indicating high plantar pressure 1
• Poor glycemic control with any neuropathy 1

Risk Stratification for Surveillance Frequency

The International Working Group on Diabetic Foot provides specific examination intervals 1:

• Very low risk (no LOPS, no PAD): Annual examination only
• Low risk (LOPS or PAD alone): Every 6-12 months
• Moderate risk (LOPS + PAD, or LOPS + deformity, or PAD + deformity): Every 3-6 months
• High risk (LOPS or PAD plus history of ulcer/amputation/end-stage renal disease): Every 1-3 months

Multidisciplinary/Interprofessional Team Referral

An interprofessional approach facilitated by podiatry is essential for 1:

• Active foot ulcers requiring wound care expertise 1
• Infected foot ulcers (moderate or severe infections require surgical consultation within 24-48 hours) 1
• Charcot neuroarthropathy requiring offloading and potential surgical reconstruction 1
• PAD with infection (requires both vascular and surgical specialist consultation urgently) 1

Key Clinical Pitfalls

Do not delay referral for patients who cannot feel the 10-g monofilament—their annual ulcer incidence is 10% without specialized care, and the number needed to treat to prevent one ulcer per year is only 18 patients. 2 For those with previous ulceration, this drops to just 7 patients. 2

Inspect feet at every visit for patients with evidence of sensory loss or prior ulceration—not just annually. 1 Fifty-four percent of diabetic foot ulcers result from preventable footwear trauma. 2

Do not rely solely on ankle-brachial index in diabetic patients, as noncompressible vessels cause inaccurate readings; toe systolic pressures <30 mmHg indicate PAD and inability to heal ulcers, requiring immediate vascular referral. 1

Patients Who Do NOT Require Routine Podiatry

Patients with diabetes who have normal protective sensation (can feel 10-g monofilament), no PAD, no foot deformities, and no history of ulceration can be managed with annual comprehensive foot examinations and patient education alone. 1 Their annual ulcer incidence is only 0.5%, making the number needed to treat 367 patients to prevent one ulcer per year. 2