What is the recommended management approach for a patient with diabetes and a history of foot complications during diabetic foot rounds?

Diabetic Foot Rounds: Recommended Management Approach

All patients with diabetes and a history of foot complications require structured multidisciplinary care with examination frequency every 1-3 months, risk-stratified assessment, patient education on daily foot inspection and appropriate footwear, and immediate referral protocols for new ulcers or infections. 1

Risk Stratification and Examination Frequency

Patients with a history of foot ulceration or lower-extremity amputation are classified as IWGDF Category 3 (highest risk) and require examination every 1-3 months. 1, 2

Comprehensive Examination Components

Each examination must systematically assess:

History Assessment:

• Previous ulcer/amputation details 1
• End stage renal disease status 1
• Previous foot education received 1
• Social isolation and healthcare access barriers 1
• Barefoot walking behaviors 1
• Claudication or rest pain symptoms 1

Vascular Assessment:

• Palpation of dorsalis pedis and posterior tibial pulses 1
• Ankle-brachial index if symptoms or signs of peripheral arterial disease present 1, 3
• History of claudication, rest pain, or decreased walking speed 3

Neurological Assessment:

• 10-g Semmes-Weinstein monofilament testing (primary test for loss of protective sensation) 1, 2
• 128-Hz tuning fork for vibration perception 1, 2
• Pin prick discrimination on dorsum of foot 1
• Achilles tendon reflexes 1

Dermatological Assessment:

• Callus formation (indicates increased plantar pressure) 1
• Skin color, temperature differences, and edema 1
• Pre-ulcerative signs 1

Musculoskeletal Assessment:

• Foot deformities including claw toes, hammer toes, bunions, prominent metatarsal heads 1
• Charcot foot changes 2
• Limited joint mobility 1

Footwear Assessment:

• Inspect both inside and outside of shoes worn at home and outside 1

Patient Education Protocol

Education must be delivered in multiple structured sessions over time using mixed methods, with verification that the patient and family understand and can demonstrate skills. 1

Critical Daily Self-Care Instructions

Daily foot inspection requirements:

• Inspect all foot surfaces including between toes daily 1
• Use unbreakable mirror if loss of protective sensation present 1, 3
• Notify healthcare provider immediately if increased temperature, blisters, cuts, scratches, or ulcers develop 1

Footwear behaviors:

• Never walk barefoot, in socks only, or in thin-soled slippers indoors or outdoors 1, 2
• Inspect inside all shoes before wearing 1
• Wear prescribed therapeutic footwear consistently 2

Hygiene practices:

• Wash feet daily with water temperature below 37°C 1
• Dry carefully, especially between toes 1
• Apply emollients to dry skin but not between toes 1
• Never use heaters or hot-water bottles on feet 1

Nail care:

• Cut toenails straight across 1
• Never use chemical agents or plasters for corns/calluses 1

Therapeutic Footwear Prescription

For Category 3 patients (history of ulcer/amputation), prescribe therapeutic footwear with demonstrated 30% plantar pressure relief compared to standard therapeutic footwear. 2

• Patients with neuropathy or increased plantar pressures require well-fitted walking shoes or athletic shoes that cushion feet and redistribute pressure 1, 3
• Patients with bony deformities need extra wide or deep shoes 1, 3
• Patients with severe deformities including Charcot foot require custom-molded shoes if commercial therapeutic footwear cannot accommodate 3

Management of Active Ulcers

When new ulcers develop, immediate assessment must include probe-to-bone test and plain radiographs, followed by MRI if soft tissue abscess or osteomyelitis suspected. 4

First-line therapies for active diabetic foot ulcers:

• Surgical debridement 4, 5
• Off-loading with total contact cast or irremovable fixed ankle walking boot for plantar ulcers 4
• Treatment of lower extremity ischemia 4, 5
• Treatment of foot infection 4, 5

For ulcers failing to improve (>50% wound area reduction) after minimum 4 weeks of standard wound therapy, add adjunctive wound therapy options. 4

Patients with diabetic foot ulcer and peripheral arterial disease require revascularization by either surgical bypass or endovascular therapy. 4

Multidisciplinary Team Referral

Multidisciplinary care involving podiatrists, infectious disease specialists, and vascular surgeons in collaboration with primary care is associated with lower major amputation rates (3.2% vs 4.4%; odds ratio 0.40). 5

Immediate referral to multidisciplinary foot team indicated for:

• New ulceration 1
• Signs of infection (fever, erythema >1.5 cm surrounding ulcer, purulent discharge) 1
• Suspected osteomyelitis 1
• Critical limb ischemia 3

Systemic Risk Factor Management

Optimize glycemic control targeting HbA1c <7% to reduce microvascular complications and improve limb-related outcomes including lower amputation rates. 3

Smoking cessation interventions combining behavioral therapy and pharmacotherapy (nicotine replacement, bupropion, or varenicline) must be offered at every clinical encounter. 3

For patients with peripheral arterial disease:

• Aspirin 75-325 mg daily as first-line antiplatelet therapy 3
• ACE inhibitors for symptomatic PAD to reduce cardiovascular events by approximately 25% 3

Common Pitfalls to Avoid

• Do not rely solely on pedal pulse palpation; obtain ankle-brachial index when clinical suspicion of PAD exists 3
• Do not assume absence of symptoms excludes foot disorders; patients may have asymptomatic neuropathy, PAD, or even ulcers 1
• Beta-blockers do not worsen claudication and are safe in PAD patients 3
• Patients with visual difficulties, physical constraints, or cognitive problems require family member assistance with foot care 1, 3