What are the current guidelines for preventing diabetic foot in patients with diabetes?

Current Guidelines for Prevention of Diabetic Foot

All patients with diabetes should undergo systematic foot screening using the IWGDF risk stratification system, with screening frequency and preventive interventions tailored to their specific risk category. 1

Risk Stratification and Screening Frequency

The IWGDF 2023 guidelines establish a four-tier risk classification system that determines screening intervals and intensity of preventive care 1:

• IWGDF Risk 0 (Very Low): No loss of protective sensation (LOPS) and no peripheral artery disease (PAD) — screen annually 1
• IWGDF Risk 1 (Low): LOPS or PAD present — screen every 6-12 months 1
• IWGDF Risk 2 (Moderate): LOPS + PAD, or LOPS + foot deformity, or PAD + foot deformity — screen every 3-6 months 1
• IWGDF Risk 3 (High): LOPS or PAD plus history of foot ulcer, lower extremity amputation, or end-stage renal disease — screen every 1-3 months 1

The rationale for this stratification is compelling: patients with a history of ulceration face a 40% recurrence rate within one year and 65% within three years after healing 1, 2, 3

Patient Education (Strong Recommendation)

Provide structured education to all at-risk patients (IWGDF risk 1-3) covering these specific behaviors 1:

• Never walk barefoot, in socks without shoes, or in thin-soled slippers — indoors or outdoors 1
• Daily foot washing with careful drying between toes, followed by emollient application to dry skin 1
• Daily foot inspection with immediate contact of healthcare provider if pre-ulcerative lesions are detected 1
• Cut toenails straight across to prevent ingrown nails 1

Structured education may improve foot self-care behavior and reduce ulceration risk (RR: 0.66; 95% CI: 0.37-1.19) 4

Footwear Recommendations

The footwear strategy depends on the patient's specific risk profile 1:

For IWGDF Risk 1-3 with No Significant Deformity:

• Educate patients to wear properly fitting footwear that accommodates foot shape 1

For IWGDF Risk 2-3 with Foot Deformity or Pre-ulcerative Lesions:

• Consider prescribing extra-depth shoes, custom-made footwear, custom-made insoles, and/or toe orthoses 1

For IWGDF Risk 3 with Healed Plantar Ulcer:

• Prescribe therapeutic footwear with demonstrated plantar pressure-relieving effect during walking 1
• Strongly encourage consistent wear both indoors and outdoors — this is critical as pressure-optimized therapeutic footwear likely reduces plantar ulcer recurrence (RR: 0.62; 95% CI: 0.26-1.47) 4

Temperature Monitoring for High-Risk Patients

Consider coaching IWGDF risk 2-3 patients to perform daily foot skin temperature self-monitoring 1. This intervention likely reduces first or recurrent plantar foot ulcers (RR: 0.51; 95% CI: 0.31-0.84) 4:

• If temperature difference between corresponding regions of left and right foot exceeds 2.2°C (4.0°F) on two consecutive days, instruct patient to reduce ambulatory activity and consult healthcare professional immediately 1

Treatment of Pre-ulcerative Lesions

Provide appropriate treatment for any pre-ulcerative lesion, excess callus, ingrown toenails, and fungal infections in all at-risk patients 1. Evidence shows callus removal reduces peak plantar pressure 5

For Non-rigid Hammertoe with Complications:

• Consider digital flexor tendon tenotomy for treating nail changes, excess callus, or pre-ulcerative lesions on the apex or distal part of the toe 1
• Alternatively, consider orthotic interventions such as toe silicone or semi-rigid orthotic devices 1
• Flexor tenotomy may reduce foot ulceration risk based on low certainty evidence 4

Foot-Ankle Exercise Program

Consider advising IWGDF risk 1-2 patients to participate in an 8-12 week foot-ankle exercise program 1. These exercises may improve neuropathy symptoms and foot/ankle joint range of motion, though evidence for pressure reduction is conflicting 5

What NOT to Do

Do not use nerve decompression procedures to prevent foot ulcers in at-risk patients — evidence is insufficient 1

Common Pitfalls to Avoid

• Failing to assess vascular status before implementing preventive strategies — patients with ankle pressure <50 mmHg or ABI <0.5 require urgent vascular evaluation 2, 3
• Inadequate patient education about early warning signs and proper footwear use 3
• Not prescribing therapeutic footwear for healed plantar ulcers — this is a strong recommendation with moderate quality evidence 1
• Inconsistent screening intervals — the recurrence rate is extremely high (40% at one year), making regular follow-up essential 1, 2