Diabetic Foot Care Guidelines

Risk Factors and Prevention

The American Diabetes Association recommends that all patients with diabetes undergo a comprehensive foot examination at least annually to identify risk factors for ulceration and amputation, with more frequent examinations for those at higher risk 1, 2
Poor glycemic control is a risk factor for diabetic foot complications, according to the American Diabetes Association 3, 1
Peripheral neuropathy with loss of protective sensation (LOPS) is a significant risk factor for diabetic foot ulcers, as stated by the American Diabetes Association 3, 1
The International Working Group on the Diabetic Foot (IWGDF) recommends classifying patients into risk categories to guide management, with Category 0 being no peripheral neuropathy and Category 3 being peripheral neuropathy with a history of foot ulcer or amputation 4, 5
The American Diabetes Association suggests that patients with a history of foot ulceration or amputation should undergo examination every 1-3 months 4, 1
Cigarette smoking is a modifiable risk factor for diabetic foot complications, as noted by the American Diabetes Association 3, 1
Visual impairment is a risk factor for diabetic foot complications, according to the American Diabetes Association 3, 6
Chronic kidney disease, especially in patients on dialysis, is a risk factor for diabetic foot complications, as stated by the American Diabetes Association 3, 1

A comprehensive foot examination should include a history assessment, neurological assessment, vascular assessment, dermatological assessment, musculoskeletal assessment, and footwear assessment, as recommended by the American Diabetes Association 1, 2
The 10-g Semmes-Weinstein monofilament test is the primary test for assessing loss of protective sensation (LOPS), according to the American Diabetes Association 1, 2
Vibration perception using a 128-Hz tuning fork is an additional test for assessing LOPS, as noted by the American Diabetes Association 4, 1
Ankle-brachial index (ABI) should be performed in patients with symptoms or signs of peripheral arterial disease (PAD), as recommended by the American Diabetes Association 3, 2

Patient education on daily foot inspection, proper foot hygiene, and appropriate nail and skin care is essential for preventing diabetic foot complications, as stated by the American Diabetes Association 3, 7
Proper footwear selection, including well-fitted off-the-shelf footwear for low-risk patients and specialized therapeutic footwear for high-risk patients, is crucial for preventing diabetic foot ulcers, according to the American Diabetes Association 8, 1
Refer high-risk patients to foot care specialists and involve a multidisciplinary team for complex cases, as recommended by the American Diabetes Association 3, 2
Optimize glycemic control and address modifiable risk factors, such as smoking cessation, to prevent diabetic foot complications, as noted by the American Diabetes Association 3, 1

The American Diabetes Association recommends performing a comprehensive foot examination to document the patient's risk category, including neuropathy testing with the 10-g Semmes-Weinstein monofilament test and vibration testing with a 128-Hz tuning fork, for patients with diabetes who have evidence of peripheral neuropathy with loss of protective sensation (LOPS) and foot deformities or history of ulceration 9, 10, 11
Vascular assessment, including palpation of pedal pulses and assessment for claudication history, should be performed to identify patients with peripheral arterial disease (PAD) 10, 11, 12
A structural examination should be performed to document any foot deformities, including hammertoes, claw toes, bunions, prominent metatarsal heads, Charcot foot, or limited joint mobility, in patients with diabetes 9, 10, 11
Skin inspection should be performed to identify callus formation, pre-ulcerative signs, color changes, temperature differences, and edema in patients with diabetes 10, 11

The International Working Group on the Diabetic Foot (IWGDF) recommends using the IWGDF Risk Classification System to justify the prescription of therapeutic footwear for patients with diabetes, with Category 0 indicating no neuropathy, Category 1 indicating peripheral neuropathy alone, Category 2 indicating neuropathy with PAD and/or foot deformity, and Category 3 indicating neuropathy with history of ulcer/amputation 10, 13, 14
For Category 2 patients, the American College of Foot and Ankle Surgeons recommends prescribing therapeutic shoes with custom-made insoles 9, 14, 10
For Category 3 patients, the American Diabetes Association recommends prescribing therapeutic footwear with demonstrated 30% plantar pressure relief compared to standard therapeutic footwear 9, 14

The American College of Cardiology recommends educating patients on the importance of wearing prescribed therapeutic footwear consistently, breaking in new shoes gradually, and inspecting shoes daily for foreign objects or rough areas 9, 14, 15
Patients should be instructed to never walk barefoot, in socks only, or in thin-soled slippers, whether at home or outside, to prevent foot injuries and ulcers 9, 14, 15
Follow-up schedule should be based on risk category, with Category 1 patients requiring follow-up every 6 months, Category 2 patients requiring follow-up every 3-6 months, and Category 3 patients requiring follow-up every 1-3 months 10, 13