Diagnosis

• Overall, 20–40% of people with diabetes have neuropathy and 20–40% have peripheral vascular disease (PVD), which are secondary to poor blood glucose control and adverse arterial risk factors (such as smoking or dyslipidaemia)
• 5% of people with diabetes may develop a foot ulcer in any year, amputation rates 0.5% per year
• MDT should normally include a diabetologist, a surgeon with the relevant expertise in managing diabetic foot problems, a diabetes nurse specialist, a podiatrist and a tissue viability nurse

MDT should:

• Assess interventions to reduce risk of cardiovascular events, CKD or anaemia
• Assess response to medical or surgical treatment
• Assess the foot and need for specialist wound care
• Assess pain
• Assess vasculature
• Review treatment of any infection
• Determine need for interventions for prevention of Achilles tendon contracture
• Orthotic assessment

Investigation

Annual inspection and examination to include:

• Testing foot sensation with 10 g monofilament (max 10 sessions) or vibration (calibrated)
• Palpation of foot pulses
• Inspection for any foot deformity
• Inspection of footwear

Categorise as:

• Low current risk (normal sensation, palpable pulses)
• Increased risk (neuropathy or absent pulses or other risk factor)
• High risk (neuropathy or absent pulses plus deformity or skin changes or previous ulcer)

Ulcerated foot:

• Assess size of ulcer and signs of infection, gangrene, ischaemia, neuropathy
• X-ray to determine extent of foot problem, MRI if osteomyelitis suspected and X-ray not definitive
• Suspected diabetic foot infection: soft tissue from debrided base for culture

Management

Chronic Care

• Low risk: improve knowledge, encourage beneficial self-care
• Increased risk: refer to foot protection team (3-6 mth check), inspect feet and vascular assessment
• High risk: refer to foot protection team (1-3 mth check), inspect feet and vascular assessment
• Intensified foot education, specialist footwear/insoles, skin and nail care
• Ulcers: urgent (<24hrs) assessment by trained professional and ongoing care by MDT including podiatrists, orthotists and diabetic nurses
• Patients who would benefit from re-vascularisation should be referred promptly
• Charcot osteoarthropathy (Joint neuropathy) if red, deformity and warmth referred immediately to MDT for joint immobilisation (NB CMT is a hereditary neuromuscular condition)

Hospital Care

• Assess < 24 hrs of diabetic foot admission, named consultant responsible for overall care
• Refer to MDT < 24 hrs
• Acute Presentation Inspection: Neuropathy; Ischaemia; Ulceration; Inflammation and/or infection; Deformity; Charcot arthropathy
• Infection treatment per local guidelines, if mild offer PO with effect against Gram +ve

Ulcer Management

• Debridement, dressings and off-loading (device to stop pressure) by MDT only
• Ischaemia assessment: maybe associated with redness & pain if infected or gangrenous, hence examine peripheral pulses, tissue loss, as well as colour and temperature and ABPI where possible

NICE Source: CG10 Type 2 diabetes foot problems: Prevention and management of foot problems and CG119 Diabetic foot problems: Inpatient management of diabetic foot problems. Summary compiled by Dr D P Sheppard MBBS.