Foot care for people with diabetes

Foot ulceration is the foremost cause of hospital admission in people with diabetes (PwD) with increasing incidence of wound infection on initial presentation over the past 5 years. Foot ulcers are prone to rapidly spreading infection, resulting in overwhelming tissue destruction and often necessitating major amputation which as well as being limb threatening is also life limiting, as only around 50% of patients survive for 2 years after major amputation occurring as a result of diabetes.

The importance of multi professional working and robust care pathways ensures that patients have access to the right medical interventions at the optimum time, demonstrating that early referral to specialist care reduces amputation rates and times to healing and that multi professional team-working (inpatient and community-based/outpatient) can reduce both hospital admissions and amputation rates.

Foot ulcers in PwD are complex, often chronic wounds, which can have major long term implications for the morbidity, mortality and quality of a person’s life (Vainieri et al, 2020). They are frequently life changing and limb threatening as one in three PwD can develop foot ulcers in their lifetime (Armstrong et al, 2017). Kerr (2017) noted that PwD are approximately 23-times more likely to have a toe, foot or limb amputated than those without the condition which represents a huge challenge for both primary and secondary care services.

Foot infection is the most common complication of diabetes requiring acute admission to hospital as well as being the most common cause of non-traumatic lower limb amputation (National Institute for Health and Clinical Excellence, 2002), with foot ulcers preceding more than 80% of amputations in PwD, (Pecoraro et al, 1990).

Foot ulcer risk assessment

Community services are increasingly at the forefront of caring for PwD, and an essential part of that care involves foot screening in order to determine the risk of ulceration (Rawles, 2014), as it has been suggested that as much as 80% of diabetes-related amputations are avoidable (Diabetes UK, 2019).

How to perform a foot check

When carrying out a foot check health care practitioners should take a full diabetes history, and then carry out the following assessment:

• remove shoes and socks/stockings
• test foot sensations using 10g monofilament or vibration with a tuning fork or Ipswich Touch Test
• palpate foot pulses
• inspect for any deformity or discolouration
• inspect for significant callus
• check for signs of ulceration
• ask about any previous ulceration
• inspect footwear
• tell patient how to look after their feet and provide written information
• tell patient their risk status and what it means
• explain what to

Procedure

Best practice on how to manage diabetes foot ulcers

There are predominately two types of foot ulcers in diabetes (Table 2): neuropathic ulcers which occur in patients with a loss of peripheral pain sensation (Figure 4) and ischaemic ulcers which occur in people with a deficient blood supply to the extremities (Figure 5).

Table 2. Comparison of neuropathic and ischaemic ulceration

Risks & Complications

Infection is common across all types of ulceration, often spreading rapidly through the foot often resulting in major tissue destruction (Figure 6).

The signs of a red, hot, swollen foot should not be underestimated as the progression from an initial relatively minor injury to unsalvageable tissue necrosis and overt gangrene can take as little as 48 hours (Edmonds et al, 2019).

The images in Figure 7 illustrate the speed at which an infection can develop in both the neuropathic foot and the ischaemic foot.

The iDEAL Diabetes group (a multi-disciplinary team of clinical specialists with a key interest in improving diabetes care outcomes for PwD across the UK) collaborated to publish a position statement (Edmonds et al, 2019) which sets out clear, structured and concise recommendations and is of great clinical relevance especially when we are working in remote virtual or digital environments.

Foot care advice for people with diabetes (regardless of risk status) can be given by any healthcare practitioner at any point in the care pathway. Advice includes:

• check their feet every day
• be aware of loss of sensation
• look for discolouration
• look for changes in the shape of their foot
• not use corn removing plasters or blades
• know how to look after their toenails
• wear shoes that fit properly
• maintain good blood glucose control
• attend their annual foot review

The ACT NOW checklist (Figure 8) was developed to be routinely adopted

iDEAL recommends that the assessment tool (Table 4) should be used for all PwD who present:

• with any foot problem
• by all practitioners
• in all locations and,
• that the initial foot assessment should be in primary or community care or through community podiatry, or community nursing
• with referral made by telephone or email to the multi-disciplinary diabetes foot care teams (with as much supporting information) if required (Edmonds et al, 2019)

Use of the ACTNOW assessment tool will ensure consistency in each individual assessment  as the individual clinician’s skill and judgement regarding the need for escalation to a specialist centre will as a result of a structured clinical history and examination as well as their own experience.

In addition, additional red flag indicators should be noted which necessitate the need for urgent referral to a specialist clinic for further assessment and treatment:

• the acutely red / hot / swollen foot

References

Armstrong DG, Boulton AJ, Bus SA. Diabetic foot ulcers and their recurrence. N.Engl.J.Med. 2017;376:2367-2375

Diabetes UK. Number of People With Diabetes Reaches 4.7 Million. 2019. https://www.diabetes.org.uk/about_us/news/new-stats-people-living-with-diabetes (accessed 9 December 2022)

Edmonds ME, Phillips A, Grumitt J et al. iDEAL Group Position Statement: ACT NOW! Diabetes and Foot Care Assessment and Referral. 2019. https://idealdiabetes.com/wp-content/uploads/2020/11/iDEAL-Diabetes-ACT-NOW-Diabetes-and-Foot-Health.pdf (accessed 9 December 2022)

Kerr M. “Diabetic Foot Care in England: An Economic Study”.  Insight Health Economics. 2017.

Kinlay, S. Management of Critical Limb Ischemia. Circulation: Cardiovascular Interventions. 2016;9(2). https://doi.org/10.1161/CIRCINTERVENTIONS.115.001946.

Miller JD, Carter E, Shih J et al. The 3-minute diabetic foot exam. J Family Practice 2014; 63(11): 646–56

National Institute for Health and Clinical Excellence. Principles for Best Practice in Clinical Audit. 2002. https://www.nice.org.uk/media/default/About/what-we-do/Into-practice/principles-for-best-practice-in-clinical-audit.pdf (accessed 9 December 2022)

Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care. 1990;13(5): https://doi.org/10.2337/diacare.13.5.513

Phillips A, Edmonds M. ACT NOW in diabetes and foot