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Diabetic foot

Definition
Diabetic foot is a complication of diabetes characterized by a triad of neuropathy, ischemia, and infection.
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Pathophysiology
Diabetic foot is caused due to uncontrolled diabetes leading to the development of peripheral neuropathy (loss of sensation) and PAD (ischemia).
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Disease course
Clinical manifestations due to peripheral neuropathy lead to fissures, bullae, Charcot joint, edema, digital necrosis; and ischemia lead to pain at rest, ulceration on foot margins, digital necrosis, and gangrene. Disease progression may lead to osteomyelitis (chronic discharging sinus and sausage-like appearance of the toe) and gangrene formation that may require amputation.
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Prognosis and risk of recurrence
The all-cause mortality related to diabetic foot ulcer and lower extremity amputation is 42.54 per 1,000 person-years and 86.80 per 1,000 person-years.
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Key sources
The following summarized guidelines for the evaluation and management of diabetic foot are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2024) and the Society for Vascular Medicine (SVM/SVS/APMA 2016).
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Guidelines

1.Screening and diagnosis

Indications for screening, average-risk patients, ADA: obtain comprehensive foot evaluations at least annually to identify risk factors for ulcers and amputations.
A
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  • Indications for screening (high-risk patients)

  • Indications for screening (pediatric patients)

2.Diagnostic investigations

Medical history: elicit a history of ulceration, amputation, Charcot foot, angioplasty or vascular surgery, cigarette smoking, retinopathy, and renal disease and assess current symptoms of neuropathy (pain, burning, numbness) and vascular disease (leg fatigue, claudication).
B

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  • Physical examination

  • Ankle-brachial index

3.Medical management

Interprofessional care: ensure an interprofessional approach facilitated by a podiatrist in conjunction with other appropriate team members in patients with foot ulcers and high-risk feet (such as patients on dialysis, with Charcot foot, history of ulcers or amputation, or PAD).
B

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  • Glycemic control

4.Nonpharmacologic interventions

Therapeutic footwear: as per ADA 2024 guidelines, offer specialized therapeutic footwear in high-risk patients with diabetes, including patients with loss of protective sensation, foot deformities, ulcers, callous formation, poor peripheral circulation, and a history of amputation.
B

5.Therapeutic procedures

Revascularization
Do not perform prophylactic arterial revascularization to prevent diabetic foot ulcer.
D
Perform revascularization by either surgical bypass or endovascular therapy in patients with diabetic foot ulcer and PAD.
B

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  • Other therapies

6.Surgical interventions

Wound care
Obtain frequent evaluation at 1-4-week intervals with measurement of diabetic foot ulcers to monitor reduction of wound size and healing progress.
B
Use dressing products maintaining a moist wound bed, controlling exudate, and avoiding maceration of surrounding intact skin in patients with diabetic foot ulcers.
B

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  • Surgical debridement

7.Patient education

Foot self-care education: as per ADA 2024 guidelines, provide general preventive foot self-care education to all patients with diabetes, including patients with loss of protective sensation, on appropriate ways to examine their feet (palpation or visual inspection with an unbreakable mirror) for daily surveillance of early foot problems.
B

8.Follow-up and surveillance

Indications for specialist referral: refer smoker patients or patients with a history of prior lower extremity complications, loss of protective sensation, structural abnormality, or PAD to foot care specialists for ongoing preventive care and life-long surveillance.
B