What is the management plan for an elderly diabetic patient with hypertension (HTN) and hyperlipidemia presenting with plantar foot pain, horn calluses, and pain relief with rest?

Management of Diabetic Foot with Plantar Calluses and Pain

This patient requires immediate professional callus debridement, therapeutic footwear with custom insoles, and structured foot care education with follow-up every 1-3 months. 1

Immediate Risk Assessment and Classification

This patient presents with pre-ulcerative signs (horn calluses) that demand urgent intervention to prevent ulceration, which carries significant morbidity and mortality risk in diabetic patients. 1

Perform comprehensive neuropathy assessment immediately: 1

• Test pressure perception with 10-g Semmes-Weinstein monofilament 1, 2
• Assess vibration perception with 128-Hz tuning fork 1
• Check Achilles tendon reflexes 1
• Evaluate for loss of protective sensation, which dramatically increases ulceration risk 2

Assess vascular status: 1

• Palpate pedal pulses bilaterally 1
• If pulses diminished, measure ankle-brachial index (ABI) 2, 3
• Note: ABI may be falsely elevated in diabetics due to arterial calcification; consider toe pressure or TcPO2 if ABI >1.3 3

Classify the patient using IWGDF Risk Categories: 1

• Category 2 (if neuropathy + foot deformity present): requires follow-up every 3-6 months 1
• Category 3 (if prior ulcer/amputation history): requires follow-up every 1-3 months 1

Immediate Treatment of Pre-Ulcerative Signs

Professional callus debridement is mandatory and should be performed immediately by a trained foot care specialist. 1 This is a strong recommendation because callus removal prevents pressure buildup that leads to ulceration. 1, 2 Debridement should be repeated regularly until the pre-ulcerative signs resolve and do not recur. 1

Critical caveat: Never allow the patient to use chemical agents or plasters to remove callus themselves—this significantly increases ulceration risk. 1

Therapeutic Footwear Prescription

Prescribe therapeutic footwear with custom-made insoles immediately. 1 This is a strong recommendation for patients with foot deformities and pre-ulcerative signs. 1

Specific footwear requirements: 1, 2

• Internal shoe length: 1-2 cm longer than the foot 1
• Internal width: equal to foot width at metatarsophalangeal joints 1
• Adequate height to accommodate all toes without pressure 1
• Assess fit while patient is standing, preferably at end of day 1, 2

For recurrent plantar ulcer prevention, prescribe footwear demonstrating 30% plantar pressure reduction compared to standard therapeutic footwear. 1 This is a strong recommendation with moderate quality evidence. 1

Rigid orthotic devices have shown significant reduction in callus grade after 12 months compared to conventional treatment alone, presumably through lowering and redistributing abnormal foot pressures. 4

Patient Education and Self-Care Instructions

Provide structured, repeated education covering: 1

Daily foot inspection: 1

• Inspect feet and inside of shoes daily 1
• Check for increased temperature, blisters, cuts, or ulcers 1
• If patient cannot perform inspection due to visual impairment, identify a family member or caregiver to assist 1

Footwear behavior: 1

• Never walk barefoot, in socks only, or in thin-soled slippers—whether at home or outside 1
• This is a strong recommendation because inappropriate footwear and barefoot walking are major causes of ulceration 1

Daily foot hygiene: 1

• Wash feet daily with water temperature below 37°C 1
• Dry carefully, especially between toes 1
• Apply emollients to lubricate dry skin, but not between toes 1
• Cut toenails straight across 1

Immediate reporting triggers: 1

• Notify healthcare provider immediately if foot temperature markedly increased 1
• Report any blister, cut, scratch, or ulcer development 1

Integrated Follow-Up Care Plan

Establish integrated foot care program with regular professional follow-up: 1

• Schedule professional foot treatment every 1-3 months based on risk category 1
• This strong recommendation is based on evidence that integrated care (professional treatment + appropriate footwear + education) significantly reduces ulcer occurrence 1, 2

Consider home temperature monitoring: 1

• Daily foot skin temperature monitoring can identify early inflammation before ulceration develops 1, 2
• This is a weak recommendation with moderate quality evidence 1

Surgical Consideration

If conservative treatment fails and pre-ulcerative signs persist or worsen, consider digital flexor tenotomy. 1, 2 This procedure showed 0-20% recurrence rates with no ulcer occurrence in 58 patients with impending ulcers. 2 However, this is a weak recommendation and should only be considered after conservative measures have been exhausted. 1

Common Pitfalls to Avoid

Do not delay callus debridement—waiting increases ulceration risk exponentially in neuropathic feet. 1, 2

Do not rely solely on patient self-care for callus management—professional debridement is essential. 1

Do not prescribe off-the-shelf footwear for patients with neuropathy and deformities—therapeutic footwear with demonstrated pressure reduction is required. 1

Do not underestimate the importance of patient adherence to wearing prescribed footwear—even the best therapeutic shoes are ineffective if not worn consistently, both indoors and outdoors. 1