Hosted by Ray Shields, MD

Foot ulcers and amputations are a major cause of complications and disability for adults with diabetes.  However, they are among the most common preventable complications from diabetes.  Early recognition and management of independent risk factors for ulcers and amputations can prevent or delay the onset of adverse outcomes.

Foot Inspection at Each Visit

Approximately one in five patients with diabetes who present for routine care will have a condition that requires prompt attention including large calluses, bacterial or fungal infections, bulky or ingrown nails, or frank ulceration. Accordingly, shoes should be removed and feet inspected for acute problems at each visit.

Annual Complete Foot Examination

Examination should include assessment of protective sensation, foot structure and biomechanics, vascular status, and skin integrity. Test sensation with the 10 g monofilament on the plantar aspect of the first, third, and fifth digits and metatarsal heads of each foot.  If the patient has no sensation on one or more of the tested sites, he or she is at high risk of developing an ulcer.  Inspect the foot for deformities and altered biomechanics including hammer or claw toe deformities, bunions, Charçot foot, any bony prominence, and excessive pronation.  Additionally, patients with a history of prior non-traumatic ulceration or amputation are at high risk.

Conduct a vascular assessment by feeling for the dorsalis pedis and posterior tibial pulses on each foot.  Alternatively, assess vascular status with an ankle brachial index (ABI).  An absent pulse or ABI ratio of <0.9 on either foot confers high risk. Keep in mind these results may be falsely elevated in diabetics due to calcification of the arteries.  

Patients with low-risk feet should be re-examined yearly with interventions aimed at controlling blood glucose, blood pressure, and lipids, and to encourage patients who use tobacco to quit.

People with high-risk foot conditions should have their feet re-examined every 1-3 months with the goal of protecting the foot from injury through patient education, podiatry care, and protective footwear. Education should stress:

·        Washing and inspecting feet on a daily basis.

·        Clearing walking areas of dangerous objects.

·        Selecting and using appropriate and properly fitted footwear.

·        Using slippers indoors (i.e., no bare feet).

·        Providing proper nail and callus care (e.g., no bathroom surgery).

·        Avoiding extreme temperatures.

·       Avoiding soaking feet.

·       Promptly reporting problems, such as infections, ulcers, and cuts that do not heal.  Advise the patient who and when to call.