Guideline 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 2023), the International Working Group on the Diabetic Foot (IWGDF/NHMRC 2022), and the Society for Vascular Medicine (SVM/SVS/APMA 2016). 1 2 3 4 4 4 5 Definition Diabetic foot is a complication of diabetes characterized by a triad of neuropathy, ischemia, and infection. 4 Epidemiology Diabetic foot is caused due to uncontrolled diabetes leading to the development of peripheral neuropathy (loss of sensation) and peripheral arterial disease (ischemia). 4 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 https://web.pathway.md/diseases/recoT1Cu8BJ5PvOdO 1/7 6/29/23, 10:12 PM Diabetic foot Pathway sinus and sausage-like appearance of the toe) and gangrene formation that may require amputation. 4 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 1000 person-years. 5 Pathway Pathway Diabetic foot Diabetic foot Management Screening and investigation Guidelines 1. Screening and diagnosis Indications for screening, average-risk patients: As per ADA 2023 guidelines, obtain a comprehensive foot evaluation at least annually to identify risk factors for ulcers and amputations. B As per SVM/APMA/SVS 2016 guidelines, perform foot inspections annually by physicians (MD, DO, DPM) or advanced practice providers with training in foot care. B Indications for screening, high-risk patients: As per ADA 2023 guidelines, obtain foot inspected at every visit in patients with evidence of sensory loss or history of ulceration or amputation. B As per SVM/APMA/SVS 2016 guidelines, consider performing annual vascular examination of the lower extremities and feet including ABI and and toe pressures in patients with diabetes and any of the following: history of diabetic foot ulcer prior abnormal vascular examination prior intervention for peripheral vascular disease known ASCVD (such as coronary, cerebral, or renal). C Indications for screening (pediatric patients): Obtain screening for diabetic neuropathy by foot examination (including foot inspection, assessment of foot pulses, pinprick and 10-g monofilament sensation tests, testing of vibration sensation using a 128-Hz tuning fork, and ankle reflex tests) at diagnosis and annually thereafter in young patients with T2DM. B Consider obtaining an annual comprehensive foot examination at the start of puberty or at age 10 years, whichever is earlier, once the patient has had T1DM for 5 years. C 2. Diagnostic investigations https://web.pathway.md/diseases/recoT1Cu8BJ5PvOdO 2/7 6/29/23, 10:12 PM Diabetic foot Pathway Clinical history: Elicit medical history of ulceration, amputation, Charcot foot, angioplasty or vascular surgery, cigarette smoking, retinopathy, and renal disease. B Assess current symptoms of neuropathy (pain, burning, numbness) and vascular disease (leg fatigue, claudication). B Physical examination: As per ADA 2023 guidelines: Include the following in the foot examination: inspection of skin assessment of foot deformities neurological assessment (10-g monofilament testing with at least one other assessment: pinprick, temperature, vibration) vascular assessment, including pulses in the legs and feet. B Assess lower extremity pulses, capillary refill time, rubor on dependency, pallor on elevation, and venous filling time for initial screening of peripheral arterial disease. B As per SVS 2016 guidelines, include testing for peripheral neuropathy using Semmes- Weinstein test in the foot examination. B Ankle-brachial index: As per ADA 2023 guidelines, obtain ABI testing and further vascular assessment as appropriate in patients with symptoms of claudication or decreased or absent pedal pulses. B As per SVS 2016 guidelines: Consider obtaining ABI measurement in patients with diabetes reached 50 years of age. C Assess pedal perfusion by ABI, ankle and pedal Doppler arterial waveforms, and either toe systolic pressure or transcutaneous oxygen pressure annually in patients with diabetic foot ulcer. B 3. Medical management Multidisciplinary management: ensure a multidisciplinary approach for patients with foot ulcers and high-risk feet (such as patients on dialysis, patients with Charcot foot, history of ulcers or amputation, or peripheral arterial disease). B Glycemic control: consider ensuring adequate glycemic control (HbA1c < 7% with strategies to minimize hypoglycemia) to reduce the incidence of diabetic foot ulcers and infections, with subsequent risk of amputation. C 4. Nonpharmacologic interventions Therapeutic footwear: As per ADA 2023 guidelines, offer specialized therapeutic footwear in high-risk patients with diabetes, including patients with loss of protective sensation, foot deformities, ulcers, callous https://web.pathway.md/diseases/recoT1Cu8BJ5PvOdO 3/7 6/29/23, 10:12 PM Diabetic foot Pathway formation, poor peripheral circulation, and a history of amputation. B As per SVS 2016 guidelines, avoid routine use of specialized therapeutic footwear in average-risk patients with diabetes. D Show 5 more 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 Negative pressure wound therapy: Consider performing negative pressure wound therapy to reduce wound size, in addition to the best standard of care, in patients with a postoperative foot ulcer. C Avoid performing negative pressure wound therapy in preference to the best standard of care in nonsurgical diabetic foot ulcers. D Hyperbaric oxygen therapy: Consider performing systemic hyperbaric oxygen therapy as an adjunctive treatment in patients with non-healing ischemic diabetic foot ulcers despite the best standard of care. C Avoid performing topical oxygen therapy as a primary or adjunctive intervention in patients with diabetic foot ulcers, including difficult-to-heal ulcers. D Other therapies: As per ADA 2023 guidelines, consider offering adjunctive treatment with RCT-proven advanced agents (such as negative-pressure wound therapy, placental membranes, bioengineered skin substitutes, several acellular matrices, autologous fibrin and leukocyte platelet patches, and topical oxygen therapy) in patients with chronic diabetic foot ulcers failed to heal with optimal standard care alone. B As per IWGDF 2022 guidelines, consider offering placenta-derived products with informed consent as an adjunctive treatment, in addition to the best standard of care, when the latter alone has failed to reduce the size of the wound. C Show 4 more As per SVS 2016 guidelines, offer the following adjunctive wound therapy options in patients with diabetic foot ulcers failing to demonstrate improvement (> 50% wound area reduction) after a minimum of 4 weeks of standard wound therapy, with the choice of adjuvant therapy based on clinical findings, availability of therapy, and cost-effectiveness: negative pressure therapy biologics (platelet-derived growth factor, living cellular therapy, extracellular matrix products, amnionic membrane products) hyperbaric oxygen therapy. B Show 4 more 6. Surgical interventions https://web.pathway.md/diseases/recoT1Cu8BJ5PvOdO 4/7 6/29/23, 10:12 PM Diabetic foot Pathway Wound care: As per IWGDF 2022 guidelines, choose dressings principally on the basis of exudate control, comfort, and cost. B Show 2 more As per SVS 2016 guidelines: 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 Surgical debridement: As per IWGDF 2022 guidelines, remove slough, necrotic tissue, and surrounding callus of a diabetic foot ulcer with sharp debridement in preference to other methods, taking into account relative contraindications such as pain or severe ischemia. B As per SVS 2016 guidelines, evaluate all patients with diabetic foot ulcer for infection on initial presentation. Perform initial sharp debridement of all infected diabetic ulcers and urgent surgical intervention for foot infections involving abscess, gas, or necrotizing fasciitis. B Show 2 more 7. Patient education Foot self-care education: As per ADA 2023 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 As per SVS 2016 guidelines, educate patients and their families about preventive foot care. 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 peripheral arterial disease to foot care specialists for ongoing preventive care and life-long surveillance. B Clinical findings Symptoms Past medical history Ankle swelling Fungal infection of the foot Burning sensation of feet Poorly controlled diabetes https://web.pathway.md/diseases/recoT1Cu8BJ5PvOdO 5/7 6/29/23, 10:12 PM Diabetic foot Pathway Changes in foot skin color and temperature Foot ulcer Leg swelling References 1. Pamela Chen, Keryln Carville, Terry Swanson et al. Australian guideline on wound healing interventions to enhance healing of foot ulcers: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. J Foot Ankle Res. 2022 May 25;15 1 40. Open 2. Anil Hingorani, Glenn M LaMuraglia, Peter Henke et al. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg. 2016 Feb;63 2 Suppl):3S 21S. Open 3. Steven E. Kahn, Cheryl A.M. Anderson, John B. Buse et al. Standards of Care in Diabetes 2023. Diabetes Care. 2023 Jan;46 Supplement_1 S1 S291. Open 4. Sharad P. Pendsey. Understanding diabetic foot. Int J Diabetes Dev Ctries. 2010 Apr-Jun; 30 2 75 79. Open 5. Khalid Al-Rubeaan, Mohammad K Almashouq, Amira M Youssef et al. All-cause mortality among diabetic foot patients and related risk factors in Saudi Arabia. 2017 Nov 27;12 11):e0188097.2017 Nov 27;12 11):e0188097. Open 6. Huang ET, Mansouri J, Murad MH et al. A clinical practice guideline for the use of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers. Undersea Hyperb Med. 2015 May-Jun;42 3 205 47. Open 7. Lipsky BA, Arag n-S nchez J, Diggle M et al. IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes Metab Res Rev. 2016 Jan;32 Suppl 1 45 74. Open 8. Game FL, Attinger C, Hartemann A et al. IWGDF guidance on use of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev. 2016 Jan;32 Suppl 1 75 83. Open 9. American Diabetes Association. Standards of Medical Care in Diabetes-2019 Abridged for Primary Care Providers. Clin Diabetes. 2019 Jan;37 1 11 34. Open 10. American Diabetes Association. 11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes 2019. Diabetes Care. 2019 Jan;42 Suppl 1 S124 S138. Open 11. American Podiatric Medical Association. Choosing Wisely APMA recommendations. Choosing Wisely. 2017. Open 12. Satish Chandra Mishra, Kunal C Chhatbar, Aditi Kashikar et al. Diabetic foot. BMJ. 2017; 359 j5064. Open 13. Khalid Al-Rubeaan, Mohammad K. Almashouq, Amira M. Youssef et al. All-cause mortality among diabetic foot patients and related risk factors in Saudi Arabia. PLoS One. 2017; 12 11 e0188097. Open 14. American Diabetes Association Professional Practice Committee, American Diabetes Association Professional Practice Committee:, Draznin B et al. Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022 Jan 1;45 Supplement_1 S1 S264. Open https://web.pathway.md/diseases/recoT1Cu8BJ5PvOdO 6/7 6/29/23, 10:12 PM Diabetic foot Pathway 15. Robert J Commons, James Charles, Jane Cheney et al. Australian guideline on management of diabetes-related foot infection: part of the 2021 Australian evidence-based guidelines for diabetes- related foot disease. J Foot Ankle Res. 2022 Jun 9;15 1 47. Open https://web.pathway.md/diseases/recoT1Cu8BJ5PvOdO 7/7