Preventive Foot Care for People with Diabetes

Foot ulcers and amputations are a great risk for people with diabetes, along with the resultant disability or death. Early recognition and treatment of risk factors for ulcers and amputations can prevent or delay the onset of these adverse outcomes. This information is intended to provide recommendations for people currently with no foot ulcers and outlines the best means to identify and manage risk factors before a foot ulcer occurs or an amputation becomes imminent.

  Risk identification is essential 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 for more than 1O years, are male, have poor glucose control, or have cardiovascular, retinal, or renal complications. The following conditions are associated with an increased risk of amputation:

v     Peripheral vascular disease.

v     Peripheral neuropathy. 

v     History of amputation and ulceration.

v     Altered biomechanics, i.e. change in gait

v     Evidence of increased pressure with the formation of callous and corns, especially callouses with             evidence of blood within the strata, blisters and erythema.

v     Limited joint mobility, bony deformity, or severe nail pathology (thickened nails)

v     Peripheral vascular disease and Peripheral neuropathy

All individuals with diabetes should receive a thorough foot examination at least twice a year to assess  sensation, foot structure and biomechanics, vascular status, and skin integrity. People with one or more high risk foot conditions should be evaluated more frequently for the development of additional risk factors. People with neuropathy should have a visual inspection of their feet at every visit with a health care professional.

Evaluation of neurological status in the low-risk foot should be carried out.  Screening for peripheral vascular disease should include a history for claudication and an assessment of the pedal pulses. The skin should be assessed for integrity, especially between the toes and under the meta­tarsal heads. The presence of erythema, warmth, or callus formation may indicate areas of tissue damage with impending breakdown. Bony deformities, limitation in joint mobility, and problems with gait and balance should be assessed.

  Distal symmetric polyneuropathy is one of the most important predictors of imminent tissue breakdown. The development of neuropathy can be delayed significantly by maintaining blood sugar levels to as near normal as possible. Stop smoking to reduce the risk of vascular disease complications.

  Suffers of neuropathy or who have evidence of increased plantar pressure may be adequately managed with well cushioned walking shoes or training shoes. Patients should be aware of the implications of sensory loss and the ways to substitute this with other senses (feeling with the hands and visual inspection) for recognition of early problems.

People with evidence of increased plantar pressure (e.g., erythema, warmth, or callus formation.) should use footwear that cushions and redistributes the pressure. Callus can be debrided with a scalpel by a chiropodist, podiatrist or other health professional with experience and training in foot care. People with bony deformities (e.g., hammertoes, 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.

People with symptoms of claudication (pain in the calves when walking) should receive further vascular assessment. Exercise therapy and surgical options may be considered.

Any body 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 (athletes foot) should be treated to prevent the development of more serious conditions.

Patients at risk should understand the implications of the loss of protective sensation, the importance of foot monitoring on a daily basis, the proper care of the foot, including nail and skin care, and the selection of appropriate foot­wear. The patient’s understanding of these issues and their physical ability to conduct proper foot surveillance and care are extremely important. Patients with neuropathy are advised to wear properly fitted footwear to minimize the formation of blisters and ulcers. Patients with visual difficulties, physical constraints preventing movement, or cognitive problems that impair their ability to assess the condition of the foot and to institute appropriate responses will need other people, such as family members, to assist in their care.  

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