Diabetes-related foot care

Diabetes foot care prevention includes examining and inspecting the feet, providing individualised education about self-management for foot care and instructions on the need for early assessment for any concerning signs of risk such as injury or deformity. 

People assessed as having intermediate-risk or high-risk feet should be offered a foot protection program. A foot protection program that includes prevention, foot care education, multidisciplinary care⁴ and close monitoring and treatment of foot ulcers can substantially reduce amputation rates. This includes podiatry review and appropriate footwear. 

Foot ulceration and limb amputation are among the major drivers of disability and healthcare costs in people with diabetes. Foot ulceration as a lifetime risk in diabetes is estimated to be 19–34%.⁵ In Australia, 12,500 people have had a diabetes-related amputation and 12 people each day may undergo a diabetes-related amputation.⁶

For information about the Foot Forward program to prevent amputation, contact Diabetes Australia. 

Patient education and support 

Foot care education should be provided to all people with diabetes to assist with the prevention of foot complications. 

Patient education and support regarding foot care should include: 

• emphasising the importance of appropriate footwear and foot care (improper footwear and tinea infection are associated with increased problems) 
• establishing a regular self-monitoring schedule (including visual checks) 
• developing an action plan to respond to early problems (eg skin breakdown). 

Assessing the risk of foot complications 

A comprehensive Diabetes and feet toolkit, published by the National Diabetes Services Scheme, is available to guide the careful assessment, prevention and management of diabetes-related foot complications.⁷ 

A careful foot assessment should be performed to stratify the risk of developing foot complications. Stratification is dependent on four risk factors:¹ 

• peripheral arterial disease (PAD), which can be assessed by dorsalis pedis and tibialis anterior pulses or hand-held Doppler; if problems are suspected, consider ankle–brachial pressure index (ABI) testing, toe–brachial index (TBI) testing or absolute toe pressure, with an understanding of the clinical limitations of each method 
• peripheral neuropathy, which can be assessed using the neuropathy disability score or a 10-g monofilament 
• deformities 
• previous amputation or ulceration. 

The following factors might also increase the risk of foot complications:¹ 

• visual impairment 
• kidney disease 
• suboptimal glucose management 
• ill-fitting footwear 
• socioeconomic disadvantage. 

To determine foot screening requirements, refer to the International Working Group on the Diabetic Foot (IWGDF) risk stratification system in the 2021 Australian guidelines for diabetes-related foot disease.² (The stratification system refers to the loss of peripheral sensation [LOPS] and peripheral artery disease [PAD].) People at intermediate and high risk should be assessed by a diabetic high-risk foot service. The intensity of monitoring and review increases according to the level of risk. 

For practice-based tools to assess circulation and foot deformity, refer to ‘Complications: Diabetes-related neuropathy’. 

Indications for immediate referral to a multidisciplinary foot care clinic include active foot disease, such as: 

• foot ulcer, with or without local Infection 
• suspected Charcot neuroarthropathy (eg unilateral, red, hot, swollen, possibly aching foot). 

Any patients presenting with acute limb ischaemia should be referred immediately to an emergency department. 

Patients with chronic limb-threatening ischaemia require urgent referral to a vascular specialist/surgeon. Look for the 5P’s: acute onset of progressive pain in the affected limb (pain), pulselessness, pallor, paraesthesia and paralysis.⁷ 

Foot ulceration 

A foot ulcer is a serious condition and needs to be managed immediately. 

Assessment 

Several wound classifications have been developed to provide objective assessment of the severity of foot ulcers. 

• The IWGDF guidelines recommend using IWGDF/Infectious Diseases Society of America (IDSA) classification criteria to assess infection severity.⁹ 

• The Wound, Ischaemia, foot Infection (WIfI) system is recommended for use in people with PAD to stratify amputation risk and revascularisation benefit.⁹

• The Site, Ischaemia, Neuropathy, Bacterial infection, Area, Depth (SINBAD) system is recommended for communication between health professionals (Table 1).¹⁰ 

If arterial insufficiency is suspected, assessment and management of the peripheral vasculature is mandatory before debridement. 

Referral to a vascular surgeon, high-risk foot clinic and/or multidisciplinary team is suggested in this situation. 

Wound management 

A patient’s ability to understand and undertake management should always be a factor in choosing a treatment and in counselling the patient regarding the treatment plan. 

The general principles of wound care include the provision of a physiologically moist wound environment and off-loading the ulcer. Off-loading of the wound can be achieved with the use of a total contact cast or other irremovable devices.¹² 

Debridement 

Local sharp debridement of non-ischaemic wounds improves healing and should be performed by a suitably qualified health professional. 

The priority of debriding wound tissue is to prepare the surface and edges of a wound to facilitate healing. Debridement also reduces pressure on the wound, allows for full inspection of tissue underneath the debrided tissue and helps drain secretions or pus.¹³

Wound dressings 

Dressings should be selected principally on the basis of exudate control, comfort and cost, and therefore be tailored to the specific characteristics of the wound. 

• In non-ischaemic ulcers, create a moist wound environment. 
• Appropriate management of wound exudate levels should be a guiding principle in dressing selection and the frequency of dressing change. 
• In ischaemic ulcers, maintain a dry wound environment using a dry, non-adherent dressing until someone with experience in PAD has reviewed the wound. 

A full list of considerations for dressing choice can be found on page 50 of the Diabetes and feet toolkit.⁶ 

Off-loading devices 

Ongoing weight bearing on an insensate foot causes continued trauma and results in poor wound healing. 

Pressure on the wound should be off-loaded, using padding or other off-loading devices, such as total contact casts and removable prefabricated devices (eg controlled ankle movement walkers, half-shoes, therapeutic shoes). 

Ulcers are often caused by patients’ footwear; if this is the case, advise the patient not to continue wearing the same shoes. 

Guidelines on footwear for people with diabetes can be found in the Diabetes and feet toolkit and in an article by van Netten et al.¹⁴ 

Infection 

The need for antibiotics should be determined on clinical grounds and appropriate choices based on what is appropriate for the patient. 

It is appropriate for cultures to be collected for identification of microbiological organisms and antibiotic sensitivities. The most appropriate tissue samples for microbiological evaluation are either deep tissue swabs after debridement or tissue/bone biopsies. 

There is no need to culture clinically uninfected ulcers, because colonising organisms will always be detected. 

Infected ulcers should be treated with antimicrobial therapy according to published antibiotic guidelines. 

The duration of therapy may need to be for extended periods. 

It is not recommended to use topical antibiotic therapy to treat mild diabetes wound infections.⁶ 

• The National Diabetes Services Scheme has resources for health professionals and people with diabetes. 
• Diabetes Feet Australia: 2021 Evidence-based Australian guidelines for diabetes-related foot disease