Diabetic Foot Care
Foot ulcers and amputations are a major cause of morbidity, disability, as well as emotional and physical costs for people with diabetes. Early recognition and management of independent risk factors for ulcers and amputations can prevent or delay the onset of adverse outcomes. This position statement provides recommendations for people who currently have no foot ulcers, and outlines the best means to identify and manage risk factors before a foot ulcer occurs or an amputation becomes imminent. These recommendations are based on the technical review of care for the nonulcerated foot in diabetes. An American Diabetes Association consensus statement covers the management of diabetic foot wounds.
Risk Identification
Risk identification is fundamental for effective preventive management of the foot in people with diabetes. The risk of ulcers or amputations is increased in people who have had diabetes ≥10 years, are male, have poor glucose control, or have cardiovascular, retinal, or renal complications. The following foot-related risk conditions are associated with an increased risk of amputation:
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Peripheral neuropathy with loss of protective sensation
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Altered biomechanics (in the presence of neuropathy)
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Evidence of increased pressure (erythema, hemorrhage under a callus)
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Bony deformity
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Peripheral vascular disease (decreased or absent pedal pulses)
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A history of ulcers or amputation
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Severe nail pathology.
Management of High Risk Condition
People with neuropathy or evidence of increased plantar pressure may be adequately managed with well-fitted walking shoes or athletic shoes. Patients should be educated on the implications of sensory loss and the ways to substitute other sensory modalities (hand palpation, visual inspection) for surveillance of early problems.
People with evidence of increased plantar pressure (e.g., erythema, warmth, callus, or measured pressure) should use footwear that cushions and redistributes the pressure. Callus can be debrided with a scalpel by a foot care specialist or other health professional with experience and training in foot care. People with bony deformities (e.g., hammertoes, prominent metatarsal heads, bunions) may need extra-wide shoes or depth shoes. People with extreme bony deformities (e.g., Charcot foot) that cannot be accommodated with commercial therapeutic footwear may need custom-molded shoes.
Initial screening for peripheral arterial disease should include a history for claudication and an assessment of the pedal pulses. Consider obtaining an ankle-brachial index, as many patients with peripheral arterial disease are asymptomatic. Refer patients with significant or a positive ankle-brachial index for further vascular assessment and consider exercise, medications, and surgical options.
People with a history of ulcers should be evaluated for the underlying pathology that led to the ulceration and be managed accordingly. Minor skin conditions such as dryness and tinea pedis should be treated to prevent the development of more serious conditions.
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