Practical guidelines on the management and prevention of the diabetic foot: Based upon the International Consensus on the Diabetic Foot (2007) Prepared by the International Working Group on the Diabetic Foot

Abstract

Foot complications are among the most serious and costly complications of diabetes mellitus. Amputation of all or part of a lower extremity is usually preceded by a foot ulcer. A strategy which includes prevention, patient and staff education, multi-disciplinary treatment of foot ulcers, and close monitoring can reduce amputation rates by 49–85%. Therefore, several countries and organizations, such as the World Health Organization and the International Diabetes Federation, have set goals to reduce the rate of amputations by up to 50%. The basic principles of prevention and treatment described in these guidelines are based on the International Consensus on the Diabetic Foot. Depending on local circumstances, these principles have to be translated for local use, taking into account regional differences in socio-economics, accessibility to healthcare, and cultural factors. These practical guidelines are aimed at healthcare workers involved in the care of people with diabetes. For more details and information on treatment by specialists in foot care, the reader is referred to the International Consensus document. Although the spectrum of foot lesions varies in different regions of the world, the pathways to ulceration are probably identical in most patients. Diabetic foot lesions frequently result from two or more risk factors occurring together. In the majority of patients, diabetic peripheral neuropathy plays a central role: up to 50% of people with type 2 diabetes have neuropathy and at-risk feet. Neuropathy leads to an insensitive and sometimes deformed foot, often with an abnormal walking pattern. In people with neuropathy, minor trauma—caused for example by ill-fitting shoes, walking barefoot, or an acute injury—can precipitate a chronic ulcer. Loss of sensation, foot deformities, and limited joint mobility can result in abnormal biomechanical loading of the foot. Thickened skin (callus) forms as a result. This leads to a further increase of the abnormal loading and, often, subcutaneous haemorrhage. Whatever the primary cause, the patient continues walking on the insensitive foot, impairing subsequent healing (Figure 1). Peripheral vascular disease, usually in conjunction with minor trauma, may result in a painful, purely ischaemic foot ulcer. Illustration of ulcer due to repetitive stress However, in patients with both neuropathy and ischaemia (neuro-ischaemic ulcer), symptoms may be absent, despite severe peripheral ischaemia. Micro-angiopathy should not be accepted as a primary cause of an ulcer. There are five key elements which underpin foot management: Regular inspection and examination of the foot at risk. Identification of the foot at risk. Education of patient, family, and healthcare providers. Appropriate footwear. Treatment of non-ulcerative pathology. All people with diabetes should be examined at least once a year for potential foot problems (Table 1). Patients with demonstrated risk factor(s) should be examined more often—every 1–6 months. Absence of symptoms does not mean that the feet are healthy; a patient might have neuropathy, peripheral vascular disease, or even an ulcer without any complaints. The feet should be examined with the patient lying down and standing up, and the shoes and socks should also be inspected. Following examination of the foot, each patient can be assigned to a risk category, which should guide subsequent management (Figure 2). Areas at risk Progression of risk categories: Sensory neuropathy and/or foot deformities or bony prominences and/or signs of peripheral ischaemia and/or previous ulcer or amputation Sensory neuropathy Non-sensory neuropathy Education, presented in a structured and organized manner, plays an important role in the prevention of foot problems. The aim is to enhance motivation and skills. People with diabetes should learn how to recognize potential foot problems and be aware of the steps they need to take in response. The educator must demonstrate the skills, such as how to cut nails appropriately. Education should be provided in several sessions over time, and preferably using a mixture of methods. It is essential to evaluate whether the person with diabetes has understood the message, is motivated to act, and has sufficient self-care skills. An example of instructions for the high-risk patient and family is given below. Furthermore, physicians and other healthcare professionals should receive periodic education to improve care for high-risk individuals. History and examination Sensory loss Daily feet inspection, including areas between the toes The need for another person with skills to inspect feet, should the people with diabetes be unable to do so (If vision is impaired, people with diabetes should not attempt their own foot care) Regular washing of feet with careful drying, especially between the toes Water temperature—always below 37 °C Do not use a heater or a hot-water bottle to warm your feet Avoidance of barefoot walking indoors or o