Diabetic Foot Problems: Prevention and Management

NICE

Latest Guidance Update

January 2023: NICE reviewed recent evidence and decided that no changes were needed to its guidance on risk assessment tools for diabetic foot problems and frequency of diabetic foot reviews.

Overview

This Guidelines summary covers preventing and managing foot problems in children, young people, and adults with diabetes. This summary contains recommendations relevant to primary care; refer to the full guideline for the complete set of recommendations.

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Assessing the Risk of Developing a Diabetic Foot Problem

Frequency of Assessments

For children with diabetes who are under 12 years, give them, and their family members or carers (as appropriate), basic foot care advice.
For young people with diabetes who are 12 to 17 years, the paediatric care team or the transitional care team should assess the young person’s feet as part of their annual assessment, and provide information about foot care. If a diabetic foot problem is found or suspected, the paediatric care team or the transitional care team should refer the young person to an appropriate specialist.
For adults with diabetes, assess their risk of developing a diabetic foot problem at the following times:
- When diabetes is diagnosed, and at least annually thereafter.
- If any foot problems arise.

Assessing the Risk of Developing a Diabetic Foot Problem

When examining the feet of a person with diabetes, remove their shoes, socks, bandages and dressings, and examine both feet for evidence of the following risk factors:
- neuropathy (use a 10 g monofilament as part of a foot sensory examination)
- limb ischaemia (see the NICE guideline on peripheral arterial disease)
- ulceration
- callus
- infection and/or inflammation
- deformity
- gangrene
- Charcot arthropathy.
Use ankle brachial pressure index in line with the NICE guideline on peripheral arterial disease. Interpret results carefully in people with diabetes because calcified arteries may falsely elevate results.
Assess the person’s current risk of developing a diabetic foot problem or needing an amputation using the following risk stratification:
- Low risk:
  - no risk factors present except callus alone.
- Moderate risk:
  - deformity or
  - neuropathy or
  - peripheral arterial disease.
- High risk:
  - previous ulceration or
  - previous amputation or
  - on renal replacement therapy or
  - neuropathy and peripheral arterial disease together or
  - neuropathy in combination with callus and/or deformity or
  - peripheral arterial disease in combination with callus and/or deformity.
- Active diabetic foot problem:
  - ulceration or
  - infection or
  - chronic limb-threatening ischaemia or
  - gangrene or
  - suspicion of an acute Charcot arthropathy, or an unexplained hot, swollen foot with a change of colour, with or without pain.

Managing the Risk of Developing a Diabetic Foot Problem

For people who are at low risk of developing a diabetic foot problem:
- continue to carry out annual foot assessments
- emphasise the importance of foot care
- advise them that they could progress to moderate or high risk.
Refer people who are at moderate or high risk of developing a diabetic foot problem to the foot protection service.
The foot protection service should assess newly referred people as follows:
- Within 2 to 4 weeks for people who are at high risk of developing a diabetic foot problem.
- Within 6 to 8 weeks for people who are at moderate risk of developing a diabetic foot problem.
For people at moderate or high risk of developing a diabetic foot problem, the foot protection service should:
- Assess the feet.
- Give advice about, and provide, skin and nail care of the feet.
- Assess the biomechanical status of the feet, including the need to provide specialist footwear and orthoses.
- Assess the vascular status of the lower limbs.
- Liaise with other healthcare professionals, for example, the person’s GP, about the person’s diabetes management and risk of cardiovascular disease.
Depending on the person’s risk of developing a diabetic foot problem, carry out reassessments at the following intervals:
- Annually for people who are at low risk, as part of their annual diabetes review.
- Frequently (for example, every 3 to 6 months) for people who are at moderate risk.
- More frequently (for example, every 1 to 2 months) for people who are at high risk, if there is no immediate concern.
- Very frequently (for example, every 1 to 2 weeks) for people who are at high risk, if there is immediate concern.
Consider more frequent reassessments for people who are at moderate or high risk, and for people who are unable to check their own feet.

Patient Information About the Risk of Developing a Diabetic Foot Problem

Provide information and clear explanations to people with diabetes and/or their family members or carers (as appropriate) when diabetes is diagnosed, during assessments, and if problems arise. Information should be oral and written, and include the following:
- Basic foot care advice and the importance of foot care.
- Foot emergencies and who to contact.
- Footwear advice.
- The person’s current individual risk of developing a foot problem.
- Information about diabetes and the importance of blood glucose control (also see recommendation below).
For guidance on education programmes and information about diabetes, see the education and information section in the NICE guideline on type 1 diabetes in adults, the education section in the NICE guideline on type 2 diabetes in adults, and the sections on education and information for children and young people with type 1 diabetes and education information for children and young people with type 2 diabetes in the NICE guideline on diabetes in children and young people.