Assessment and risk stratification of the diabetic (diabetes) foot

Assessing the risk of developing a diabetic foot problem

When examining the feet of a person with diabetes, remove their shoes, socks, bandages and dressings, and examine both feet for evidence of the following risk factors:

• neuropathy (use a 10 g monofilament as part of a foot sensory examination)
• limb ischaemia
• ulceration
• callus
• infection and/or inflammation
• deformity
• gangrene
• charcot arthropathy

Use ankle brachial pressure index - interpret results carefully in people with diabetes because calcified arteries may falsely elevate results.

Assess the person's current risk of developing a diabetic foot problem or needing an amputation using the following risk stratification:

Low risk:

• no risk factors present except callus alone

Moderate risk:

• deformity or
• neuropathy or
• non-critical limb ischaemia

High risk:

• previous ulceration or previous amputation or
• on renal replacement therapy or
• neuropathy and non-critical limb ischaemia together or
• neuropathy in combination with callus and/or deformity
• or non-critical limb ischaemia in combination with callus and/or deformity

Active diabetic foot problem - these require referral to podiatry services - see below:

• ulceration or spreading infection or
• critical limb ischaemia or
• gangrene or
• suspicion of an acute Charcot arthropathy, or
• an unexplained hot, red, swollen foot with or without pain

Managing the risk of developing a diabetic foot problem

For people who are at low risk of developing a diabetic foot problem, continue to carry out annual foot assessments, emphasise the importance of foot care, and advise them that they could progress to moderate or high risk.

Refer people who are at moderate or high risk of developing a diabetic foot problem to the foot protection service.

The foot protection service should assess newly referred people as follows:

• within 2-4 weeks for people who are at high risk of developing a diabetic foot problem
• within 6-8 weeks for people who are at moderate risk of developing a diabetic foot problem

For people at moderate or high risk of developing a diabetic foot problem, the foot protection service should:

• assess the feet. Give advice about, and provide, skin and nail care of the feet.
• assess the biomechanical status of the feet, including the need to provide specialist footwear and orthoses.
• assess the vascular status of the lower limbs.
• liaise with other healthcare professionals, for example, the person's GP, about the person's diabetes management and risk of cardiovascular disease

Depending on the person's risk of developing a diabetic foot problem, carry out reassessments at the following intervals:

• annually for people who are at low risk. Frequently (for example, every 3-6 months) for people who are at moderate risk.
• more frequently (for example, every 1-2 months) for people who are at high risk, if there is no immediate concern.
• very frequently (for example, every 1-2 weeks) for people who are at high risk, if there is immediate concern.

Consider more frequent reassessments for people who are at moderate or high risk, and for people who are unable to check their own feet.

Referral

If a person has a limb-threatening or life-threatening diabetic foot problem, refer them immediately to acute services and inform the multidisciplinary foot care service so they can be assessed and an individualised treatment plan put in place. Examples of limb-threatening and life-threatening diabetic foot problems include the following

• ulceration with fever or any signs of sepsis
• ulceration with limb ischaemia
• cllinical concern that there is a deep-seated soft tissue or bone infection (with or without ulceration)
• gangrene (with or without ulceration).

For all other active diabetic foot problems, refer the person within 1 working day to the multidisciplinary foot care service or foot protection service for triage within 1 further working day.

Reference:

• NICE (January 2016).Diabetic foot problems: prevention and management