Foot care and screening

Foot problems account for a high proportion of preventable diabetes-related hospital admissions. The long-term effects of amputations are restrictive to quality of life and costly in terms of healthcare resources. Early diagnosis of at-risk feet and proactive monitoring has been demonstrated to reduce numbers proceeding to amputation. Ulceration and amputation are not the inevitable consequences of peripheral neuropathy or peripheral vascular disease. Prevention of ulceration is effective if early recognition of the at-risk foot is achieved through routine clinical assessment. Absence of symptoms should not be taken as an indication of absence of risk. All diabetic patients must have regular foot screening and education.

WhoAll people with diabetes

WhenAt diagnosis andannually thereafter

By whomA suitably-trained individual: a training package is available from NHS Grampian Podiatry

WhereWill depend on local arrangements

HowBy inspection and clinical examination using 1st line screening diabetic foot risk assessment. Patients should be offered appropriate referral.

DocumentationShould provide an assessment of risk and record parameters in a structured fashion that can be meaningfully shared with other healthcare professionals and inform the decision on need for further assessment. See Appendix 6 for First Line Foot Screening Document.

This should then be split into the following links:

Foot Care Education

At Risk Feet

Foot Assessment

Foot Ulceration

Foot deformity

Charcot arthropathy

Painful peripheral neuropathy

Foot care education

All patients with diabetes should receive basic continuing education concerning:

  • effects of diabetes upon feet
  • care of feet
  • protection of feet

At risk feet

The presence of any of the following features indicates feet at increased risk:

  • Skin - thin, fragile, "tissue paper" skin may indicate peripheral vascular disease. Dry, cracked skin may indicate autonomic neuropathy.
  • Areas of callus or evidence of increase in pressure especially with haemorrhages underneath callus
  • History of previous foot ulceration, amputation or re-vascularisation
  • Visual impairment
  • Absence of both pulses in either foot
  • Symptoms of peripheral arterial disease
  • Active ulceration
  • Peripheral neuropathy
  • Deformity
  • Charcot joint
  • Other significant active lesions including corns, ingrowing toenails, gross nail abnormalities
  • Physical disability which prevents proper self foot care (often present in the elderly)

Foot assessment

Should be carried out initially by Diabetic 1st Line Foot Screening and according to the patient’s assessment needs, offered appropriate onward referral. Diabetic 1st Line Foot Screening package and training is available from NHS Grampian Podiatry.

Foot ulceration

  • Foot ulcers presenting with evidence of infection should be swabbed and initially treated with a broad spectrum antibiotic (e.g. ciprofloxacin, co-amoxiclav, erythromycin or flucloxacillin).
  • The wound should be irrigated with warm sterile saline, and an appropriate sterile dressing should be applied immediately. A non-touch technique should be used.
  • The patient should be referred urgently to a diabetes specialist Podiatrist for debridement of any surrounding callus or necrotic tissue, and pressure relief intervention.
  • Patients with non-healing suspected vascular ulcers require assessment of the lower limb arteries by colour doppler or angiography through the vascular surgery department.
  • Urgent referral to a Specialist Diabetes Podiatrist (by telephone or fax) is the most appropriate route for patients with a non-healing or infected diabetic ulcer.

Foot deformity

Patients with any type of foot deformity are prone to abnormal pressures, callus formation and hence ulceration. Such patients should be under regular podiatry review and will require referral for specialist footwear.

Charcot arthropathy

The finding of hot, swollen, deformed foot or ankle needs immediate specialist investigation and management. It is difficult to differentiate between Charcot arthropathy and soft tissue infection. Discuss with Diabetes Specialist Team urgently.

Painful peripheral neuropathy

This is usually manifested by a burning sensation, particularly at night and diagnosis is made on the basis of the clinical history. Effective treatment is difficult. Therapeutic approaches are largely empirical and include:

  • Optimisation of blood glucose control (may cause temporary aggravation of symptoms)
  • Simple analgesia
  • Amitriptyline 25-50 mg at night. Increased as necessary every few weeks
  • Gabapentin
  • Carbamazepine
  • Capsaicin Cream applied sparingly to the affected area
  • Op-site - occasionally this can prove surprisingly effective