Protocol · WHO HEARTS-D and PEN
Diabetic foot: examine, classify, protect
Most amputations in diabetes start with a small wound on a foot that cannot feel pain. Simple checks find the feet at risk, and good daily foot care with proper shoes prevents most ulcers. Any ulcer, infection or gangrene needs urgent referral.
- Based on WHO HEARTS-D and PEN
- For doctors, clinical officers, nurses and community health workers
- Reviewed October 2026
1Who / 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.
No symptoms does not mean no problem: many people with loss of sensation feel nothing.
2Red 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.
3Assess
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.
Ask about leg pain or cramps when walking, tingling, burning or numbness, and footwear.
4Classify
| 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 |
5Treat
- 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.
6Follow-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.
7Counsel
- 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.
8When 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.
9Sources
- World Health Organization. Diagnosis and management of type 2 diabetes (HEARTS-D). 2020 (WHO/UCN/NCD/20.1). Foot examination, risk stratification table, review intervals, referral and counselling.
- World Health Organization. WHO package of essential noncommunicable (PEN) disease interventions for primary health care. 2020 (ISBN 9789240009226). Examine feet at every visit; annual amputation-risk check.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.