General practice management of type 2 diabetes


Foot complications
×
☰ Table of contents


Recommendations

Reference

Grade*

Assess all people with diabetes and stratify their risk of developing foot complications

160
NHMRC, 2011

C

Assess risk stratification by inquiring about previous foot ulceration and amputation plus falls risk, visually inspecting the feet for structural abnormalities and ulceration, assessing for neuropathy using either the neuropathy disability score or a 10 g monofilament and palpating foot

160
NHMRC, 2011

C

People assessed as having intermediate-risk or high-risk feet should be offered a foot protection program. This includes foot care education, podiatry review and appropriate footwear

160
NHMRC, 2011

C

Pressure reduction, otherwise referred to as redistribution of pressure or offloading, is required to optimise the healing of plantar foot ulcers

160
NHMRC, 2011

B

Offloading of the wound can be achieved with the use of a total contact cast or other device rendered irremovable

160
NHMRC, 2011

B

People with diabetes-related foot ulceration are best managed by a multidisciplinary foot care team

160
NHMRC, 2011

C

*Refer to Summary, explanation and source of recommendations for an explanation of the level of evidence and grade of evidence

   

Clinical context


Foot ulceration and limb amputation are among the major drivers of disability and healthcare costs in people with diabetes. Foot ulceration accounts for one in five of all diabetes-related admissions to hospital.

Indications for immediate referral to a podiatrist include concerns about vascular and/or neuropathic complications of diabetes. Predisposing structural problems often exist, heightening complication risks. Improper footwear and tinea infection have been associated with increased podiatry problems.

A care plan and foot protection program that includes prevention, patient education, multidisciplinary care, and close monitoring and treatment of foot ulcers can substantially reduce amputation rates.

Patients should understand the importance of appropriate footwear and foot care, establish a regular self-monitoring schedule (including visual checks), and have an action plan to respond to early problems (eg skin breakdown). Regular podiatric review needs to be considered. Refer to Appendix I. Tools for assessing neuropathy circulation and foot deformity for practice-based tools for assessing circulation and foot deformity.


In practice


Foot care education should be provided to all people with diabetes to assist with prevention of foot complications. For people with intermediate and high risk, a podiatry assessment is an important component of a foot protection program. However, where this is not possible, a suitably trained healthcare worker may perform the foot assessment.

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

  • 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 index (ABI) testing, toe brachial index (TBI) testing or absolute toe pressure.
  • Neurological testing – which can be undertaken using a neuropathy disability score or a 10 g monofilament assessment.
  • Deformities and ulceration – these can be assessed by visual inspection.

Practitioners are advised to stratify foot risk according to the presence of risk factors and history of ulceration and/or amputation. The intensity of monitoring and review increases according to the level of risk. Table 10 shows risk categorisation for complications and elements to consider during foot assessment.
 

Table 10. Guidance on risk categorisation for complications and elements to consider during foot assessment160 

Stratification of foot ulceration and amputation risk in diabetes

NHMRC grade*

Foot care and education – tailored to foot risk status

Low risk

No risk factors for foot ulceration or ulceration/amputation

C

Offer basic foot care information and annual foot assessment

Intermediate risk

One risk factor only (ie neuropathy, peripheral arterial disease [PAD]) and no previous history of foot ulceration or amputation

C

Offer program that includes foot care education, podiatry review every six months and footwear assessment

High risk

Two or more risk factors (ie neuropathy, PAD or foot deformity) and/or previous foot ulceration or amputation

C

Offer program that includes foot care education, podiatry review and footwear assessment

High risk

Aboriginal or Torres Strait Islander peoples with diabetes

Practice point

Offer program that includes foot care education, podiatry review and footwear assessment

*Refer to Summary, explanation and source of recommendations for an explanation of the level of evidence and grade of evidence

Foot ulceration

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

The University of Texas wound classification system is the most useful tool for grading foot ulcers (refer to Table 11).174,175

If arterial insufficiency is suspected, assessment and management of the peripheral vasculature is mandatory before removal of non-viable or necrotic tissue is considered.

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

The first priority of management of foot ulceration is to prepare the surface and edges of a wound to facilitate healing. Local sharp debridement of non-ischaemic wounds should be performed because it improves ulcer healing. Arterial supply needs to be determined before beginning any treatment.

Wound dressings need to be tailored to the specific characteristics of the wound.

In non-ischaemic ulcers, create a moist wound environment. Currently, there is insufficient evidence to demonstrate the superiority of any one type of wound dressing over another in the management of ulcers. 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.

Table 11: University of Texas Wound Grading System174,175

Grade/depth: ‘How deep is the wound?’

Stage
/comorbidities:
‘Is the wound infected, ischaemic or both?’

Depth

Grade

 

0

I

II

III

A

Pre-ulcerative or post-ulcerative lesion completely epithelialised

Superficial wound not involving tendon, capsule or bone

Wound penetrating to tendon or capsule

Wound penetrating to bone or joint

B

Pre-ulcerative or post-ulcerative lesion completely epithelialised with infection

Superficial wound not involving tendon, capsule or bone with infection

Wound penetrating to tendon or capsule with infection

Wound penetrating to bone or joint with infection

C

Pre-ulcerative or post-ulcerative lesion completely epithelialised with ischaemia

Superficial wound not involving tendon, capsule or bone with ischaemia

Wound penetrating to tendon or capsule with ischaemia

Wound penetrating to bone or joint with ischaemia

D

Pre-ulcerative or post-ulcerative lesion completely epithelialised with infection and ischaemia

Superficial wound not involving tendon, capsule or bone with infection and ischaemia

Wound penetrating to tendon or capsule with infection and ischaemia

Wound penetrating to bone or joint with infection and ischaemia

Reproduced with permission from Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996;35(6):528–31.

Factors that favour referral to a multidisciplinary foot care team include:

  • deep ulcers (eg probe to tendon, joint or bone)
  • high-risk foot with active ulcer
  • ulcers not reducing in size after four weeks despite appropriate treatment – if in regional or remote areas, a telemedical review or telephone review would be recommended
  • the absence of foot pulses/ low ABI or TBI treading
  • ascending cellulitis
  • suspected Charcot neuroarthropathy (eg unilateral, red, hot, swollen, possibly aching foot).

If access to a multidisciplinary foot care team is limited, foot ulceration or complications other than those listed above may be managed by a GP together with a podiatrist and/or wound care nurse.160

An important reason for failure of an ulcer to heal is continued trauma to the bed of the wound. This generally occurs because the foot is insensate and the patient continues to bear weight through the wound. A number of offloading devices are currently available. These include total-contact casts and removable prefabricated devices (eg controlled ankle-movement walkers, half-shoes, therapeutic shoes). Patient ability to understand and undertake management should always be a factor in choosing a treatment and in counselling the patient regarding the treatment plan.

Infection

The need for antibiotics should be determined on clinical grounds.

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.

Infected ulcers should be treated with antimicrobial therapy according to published antibiotic guidelines. The duration of therapy may need to be for extended periods.

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


Diabetes Australian and RACGP logo's
 
  1. National Health and Medical Research Council. National evidence-based guideline: Prevention, identification and management of foot complications in diabetes. Canberra: NHMRC, 2011.
  2. Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 1998;21(5):855–59.
  3. Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996;35(6):528–31.