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Sunday, June 26, 2016

Division of Diabetes Treatment and Prevention - Leading the effort to treat and prevent diabetes in American Indians and Alaska Natives

Standards of Care and Clinical Practice
Recommendations: Type 2 Diabetes

Last updated: July 2012

Foot Care

Clinical Practice Recommendations

Foot Care

recommendations icon 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

tools and resources icon Key Tools and Resources

American Diabetes Association Position Statement: Preventive Foot Care in Diabetes. Diabetes Care. 2004 Exit Disclaimer: You Are Leaving www.ihs.gov Jan;27 Suppl 1:S63-4.

National Diabetes Education Program. Redesigning the Health Care Team: Diabetes Prevention and Lifelong Management. Centers for Disease Control and Prevention and National Institutes of Health. 2007. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  68 p.

  • A cross-training guide to reinforce consistent diabetes messages across the four disciplines – pharmacy, podiatry, optometry, and dentistry (PPOD) -- and to promote a team approach to comprehensive diabetes care that encourages collaboration among all care providers.

additional resources icon Additional Resources

IHS Division of Diabetes Treatment and Prevention.

  • Diabetes Foot Care Hub. Includes CME/CE online, Quick Guide Cards, Treatment Algorithm, educational materials, best practices, and podcasts.

Health Resources and Services Administration.

  • The Lower Extremity Amputation Prevention (LEAP) Exit Disclaimer: You Are Leaving www.ihs.gov program is a comprehensive 5-step program that can reduce lower extremity amputation rate in individuals with decreased sensation in their feet. Web site includes online course for providers on lower extremity amputation prevention and treatment of the neuropathic foot.

National Diabetes Education Program.

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Patient Education Materials

National Institute of Diabetes and Digestive and Kidney Diseases.

Prevent Diabetes Problems: Keep Your Feet and Skin Healthy. Exit Disclaimer: You Are Leaving www.ihs.gov [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. Exit Disclaimer: You Are Leaving www.ihs.gov NIH Publication No. 08-3185. 2009.

  • Online resource answering frequently asked questions related to diabetes neuropathies including peripheral neuropathy.


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. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2008;31:1679-85.

Callaghan BC, Little AA, Feldman EL, Hughes RAC. Enhanced glucose control for preventing and treating diabetic neuropathy. Exit Disclaimer: You Are Leaving www.ihs.gov 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. Exit Disclaimer: You Are Leaving www.ihs.gov [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. Exit Disclaimer: You Are Leaving www.ihs.gov [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. Exit Disclaimer: You Are Leaving www.ihs.gov 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. Exit Disclaimer: You Are Leaving www.ihs.gov 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. Exit Disclaimer: You Are Leaving www.ihs.gov 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. Exit Disclaimer: You Are Leaving www.ihs.gov [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. Exit Disclaimer: You Are Leaving www.ihs.gov J Am Podiatr Med Assoc. 2010 Jul 1;100(4):309-11.

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Division of Diabetes Treatment and Prevention | Phone: 1-844-IHS-DDTP (1-844-447-3387) | diabetesprogram@ihs.gov