Last updated: July 2012
Clinical Practice Recommendations
Recommendations for Foot Care
- Inspect patients’ feet for acute problems at each diabetes visit.
- Perform complete foot examination at least annually to include assessment of protective sensation, foot structure and biomechanics, vascular status, and skin integrity:
- Test protective sensation with a 10-gm monofilament and at least 1 of the following: vibration sensation using a 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold. Assign a category of foot risk for each patient.
- Provide risk-appropriate monitoring, treatment, and self-management education, including smoking cessation, as appropriate.
- Refer patients as needed to foot care specialists (podiatrists, wound care specialists), footwear providers, orthopedists, and vascular surgeons.
Foot ulcers and amputations due to diabetic neuropathy and/or peripheral arterial disease (PAD) are common, yet often preventable causes of disability in adults with diabetes. Because early identification and management of patients at high risk for foot problems can prevent or delay the onset of adverse outcomes, it is important to evaluate the feet of all patients with diabetes. Categories of risk are defined as:
- Low Risk: normal sensory exams, foot structure, vascular status, and skin integrity, and no prior non-traumatic ulcerations.
- High Risk: abnormalities on exam or a history of non-traumatic ulcerations.
Since 10-20% of patients with diabetes who present for routine care will have a condition that requires prompt attention (e.g., calluses, bacterial or fungal infections, bulky or ingrown nails, or frank ulceration), it is important to inspect patients’ feet at every diabetes visit, regardless of their risk category.
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Tools for Clinicians and Educators
Patient Education Materials
National Institute of Diabetes and Digestive and Kidney Diseases.
Prevent Diabetes Problems: Keep Your Feet and Skin Healthy.
[PDF] NIH Publication No. 08-4282. 2008.
- Easy-to-read illustrated booklet describing diabetes self-care to reduce risk for feet and skin problems caused by diabetes (available in large or standard format).
National Diabetes Information Clearinghouse.
Diabetic Neuropathies: The Nerve Damage of Diabetes.
NIH Publication No. 08-3185. 2009.
- Online resource answering frequently asked questions related to diabetes neuropathies including peripheral neuropathy.
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Boulton AM, Armstrong DG, Albert SF, Frykberg RG, Hellman R, Kirkman MS, et al. Comprehensive foot examination and risk assessment: a report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists.
[PDF] Diabetes Care. 2008;31:1679-85.
Callaghan BC, Little AA, Feldman EL, Hughes RAC. Enhanced glucose control for preventing and treating diabetic neuropathy.
Cochrane Database Syst Rev. 2012 Jun 13;6:CD007543.
Lavery LA, Peters EJ, Williams JR, Murdoch DP, Hudson A, Lavery DC. Reevaluating the way we classify the diabetic foot: restructuring the diabetic foot risk classification system of the International Working Group on the Diabetic Foot.
[PDF] Diabetes Care. 2008 Jan;31(1):154-6.
Mayfield JA, Reiber GE, Sanders LJ, Pogach LM. Preventive foot care in diabetes: American Diabetes Association position statement.
[PDF] Diabetes Care. 2004 Jan; 27 Suppl 1:S63-4.
Monteiro-Soares M, Boyko E, Ribeiro J, Ribeiro I, Dinis-Ribeiro M. Predictive factors for diabetic foot ulceration: a systematic review.
Diabetes Metab Res Rev. 2012 Jun 22. doi: 10.1002/dmrr.2319. [Epub ahead of print].
Reiber GE, Raugi GJ. Preventing foot ulcers and amputations in people with diabetes: future promise based on lessons learned.
Lancet. 2005 Nov 12;366(9498):1676-7.
Rith-Najarian S, Branchaud C, Beaulieu O, Gohdes D, Simonson G, Mazze R. Reducing lower-extremity amputations due to diabetes: application of the staged diabetes management approach in a primary care setting. J Fam Pract. 1998;47(2):127-32.
Rogers LC, Frykberg RG, Armstrong DG, Boulton AJM, Edmonds M, Ha Van G, et al. The Charcot foot in diabetes: consensus report of the American Diabetes Association and the American Podiatric Medical Association.
Diabetes Care. 2011 Sep;34:2123-9.
Schraer CD, Weaver D, Naylor JL, Provost E, Mayer AM. Reduction of amputation rates among Alaska Natives with diabetes following the development of a high risk foot program.
[PDF] Int J Circumpolar Health. 2004;63 Suppl 2:114-9.
Sumpio BE, Armstrong DG, Lavery LA, Andros G. The role of interdisciplinary team approach in the management of the diabetic foot: a joint statement from the Society for Vascular Surgery and the American Podiatric Medical Association.
J Am Podiatr Med Assoc. 2010 Jul 1;100(4):309-11.