Who / when
- Everyone with diabetes: look at the feet for ulcers at every visit.
- A full foot check (pulses, sensation, deformity, old or current ulcers) at least once a year.
- Higher risk: neuropathy, peripheral arterial disease, poor glucose control, smoking, kidney disease, a previous ulcer or amputation.
Red flags: refer now
Active foot problem: refer urgently
- Infected ulcer, or spreading infection (redness, swelling, pus, fever).
- Critical limb ischaemia: a cold, pale or painful foot, pain at rest, absent pulses.
- Gangrene (black or dead tissue).
- Suspected acute Charcot foot, or an unexplained red, hot, swollen foot.
Check the whole personAn ill person with a foot infection may also have very high glucose or ketoacidosis: check glucose and follow the type 2 diabetes protocol.
Assess
Remove shoes, socks and dressings. Look at both feet, including between the toes and the soles.
- Skin and nails: ulcers, blisters, cracks, calluses, fungal infection, ingrown or thickened nails, colour and temperature.
- Shape: deformity, prominent bones, changes in shape over time.
- Pulses: dorsalis pedis (top of the foot, just beside the big-toe tendon) and posterior tibial (behind the inner ankle bone).
- Sensation (one method):
- 10 g monofilament: show the person on the hand first; with their eyes closed, press until the filament bends, about 2 seconds, at three sites on each foot (beside, not on, any ulcer, callus or dead tissue). Include one sham touch.
- 128 Hz tuning fork on the back of the big-toe tip; the test is normal if 2 of 3 answers are right.
- No equipment (light-touch test): touch the tips of the first, third and fifth toes lightly with your index finger for 1 to 2 seconds. Not felt at 2 or more sites: loss of sensation likely.
Classify
| Risk level | Any of these | Action |
|---|
| Active foot problem | Ulcer; spreading infection; critical limb ischaemia; gangrene; suspected acute Charcot foot; unexplained red, swollen foot | Urgent referral |
| High risk | Previous ulcer or amputation; neuropathy with reduced blood supply; neuropathy with callus or deformity; reduced blood supply with callus or deformity | Review every 1 to 3 months |
| Moderate risk | Deformity; neuropathy; reduced (not critical) blood supply | Review every 3 to 6 months |
| Low risk | No risk factor except callus alone | Review once a year |
Treat
- Pre-ulcer lesions need a trained health worker: remove callus, protect or drain blisters, treat ingrown or thickened nails, treat fungal infection.
- Control glucose, BP and lipids, and help the person stop smoking (see the type 2 diabetes and CVD risk protocols).
- Ulcer: refer if a trained professional, equipment and dressings are not available at your level. Clean, protect, and keep weight off the foot on the way.
- Antibiotics for infection: choice and dose per national formulary; do not let them delay referral.
Also referGross foot deformity, absent foot pulses, or suspected reduced blood supply to the leg: refer to a higher level of care for assessment.
Follow-up
- Look at the feet at every visit.
- Review interval by risk level (see Classify). Re-check the risk level at least once a year.
- After any ulcer has healed, the person stays at high risk.
Counsel
- Look at your feet every day, including between the toes; use a mirror for the soles.
- Wash daily in lukewarm water (test it as for a baby), dry well between the toes.
- Moisturise dry skin, but not between the toes.
- Cut nails straight across; do not cut corns or calluses yourself or use corn plasters.
- Never walk barefoot, even at home. Shoes should be 1 to 2 cm longer than the foot, not tight. Feel inside shoes before putting them on.
- Do not smoke. Keep glucose under control.
- Come the same day for any cut, blister, redness or swelling.
Your feet may not feel pain, so a small wound can become serious without you noticing. Look at them every day and always wear shoes.
When to refer
- Urgently: infected ulcer, spreading infection, critical limb ischaemia, gangrene, suspected acute Charcot foot, unexplained red swollen foot.
- Any foot ulcer that cannot be managed by a trained professional at your level.
- Gross deformity or absent pulses; suspected peripheral arterial disease.
Sources
World Health Organization. Diagnosis and management of type 2 diabetes (HEARTS-D). 2020. World Health Organization. WHO package of essential noncommunicable (PEN) disease interventions for primary health care. 2020.