Prevention of Diabetic Foot Ulcers

Risk Stratification and Screening

The International Working Group on the Diabetic Foot (IWGDF) recommends a four-tier risk classification system to determine screening intervals and intensity of preventive care for patients with diabetes, with screening frequency tailored to their specific risk category 1, 2, 3
Patients with a history of ulceration face a 40% recurrence rate within one year and 65% within three years after healing, highlighting the importance of regular screening 2, 4, 5
The IWGDF risk classification system includes:

The IWGDF recommends providing structured education to all at-risk patients (IWGDF risk 1-3) covering specific behaviors, including never walking barefoot, daily foot washing and drying, daily foot inspection, and proper toenail cutting 1
Structured education may improve foot self-care behavior and reduce ulceration risk 1

The IWGDF recommends educating patients to wear properly fitting footwear that accommodates foot shape 1
For patients with foot deformity or pre-ulcerative lesions, consider prescribing extra-depth shoes, custom-made footwear, custom-made insoles, and/or toe orthoses 1
For patients with healed plantar ulcers, prescribe therapeutic footwear with demonstrated plantar pressure-relieving effect during walking 1

Consider coaching high-risk patients to perform daily foot skin temperature self-monitoring to reduce the risk of plantar foot ulcers 1

Provide appropriate treatment for any pre-ulcerative lesion, excess callus, ingrown toenails, and fungal infections in all at-risk patients 1
Consider digital flexor tendon tenotomy for treating nail changes, excess callus, or pre-ulcerative lesions on the apex or distal part of the toe 1

Consider advising patients to participate in an 8-12 week foot-ankle exercise program to improve neuropathy symptoms and foot/ankle joint range of motion 1

Do not use nerve decompression procedures to prevent foot ulcers in at-risk patients — evidence is insufficient 1

Failing to assess vascular status before implementing preventive strategies — patients with ankle pressure <50 mmHg or ABI <0.5 require urgent vascular evaluation 4, 5
Inadequate patient education about early warning signs and proper footwear use 5
Not prescribing therapeutic footwear for healed plantar ulcers — this is a strong recommendation with moderate quality evidence 1
Inconsistent screening intervals — the recurrence rate is extremely high (40% at one year), making regular follow-up essential 2, 4