Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The full list of recommendations is in section 1.

See implementation: getting started for information about putting the recommendations on dermoscopy, managing suboptimal vitamin D levels, sentinel lymph node biopsy and completion lymphadenectomy into practice.

Care within 24 hours of a person with diabetic foot problems being admitted to hospital, or the detection of diabetic foot problems (if the person is already in hospital)

  • Each hospital should have a care pathway for people with diabetic foot problems who need inpatient care. [2011]

Care across all settings

  • Commissioners and service providers should ensure that the following are in place:

    • A foot protection service for preventing diabetic foot problems, and for treating and managing diabetic foot problems in the community.

    • A multidisciplinary foot care service for managing diabetic foot problems in hospital and in the community that cannot be managed by the foot protection service. This may also be known as an interdisciplinary foot care service.

    • Robust protocols and clear local pathways for the continued and integrated care of people across all settings, including emergency care and general practice. The protocols should set out the relationship between the foot protection service and the multidisciplinary foot care service.

    • Regular reviews of treatment and patient outcomes, in line with the National Diabetes Foot Care Audit.

Assessing the risk of developing a diabetic foot problem

  • For adults with diabetes, assess their risk of developing a diabetic foot problem at the following times:

    • When diabetes is diagnosed, and at least annually thereafter (see recommendation 1.3.11).

    • If any foot problems arise.

    • On any admission to hospital, and if there is any change in their status while they are in hospital.

  • 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 (see the NICE guideline on lower limb peripheral arterial disease).

    • Ulceration.

    • Callus.

    • Infection and/or inflammation.

    • Deformity.

    • Gangrene.

    • Charcot arthropathy.

  • 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:

      • 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.

Diabetic foot problems

  • 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 (according to local protocols and pathways; also see recommendation 1.2.1), 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 (see the NICE guideline on lower limb peripheral arterial disease).

    • Clinical 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 (according to local protocols and pathways; also see recommendation 1.2.1) for triage within 1 further working day.

Diabetic foot infection

  • All hospital, primary care and community settings should have antibiotic guidelines covering the care pathway for managing diabetic foot infections that take into account local patterns of resistance.

Charcot arthropathy

  • Suspect acute Charcot arthropathy if there is redness, warmth, swelling or deformity (in particular, when the skin is intact), especially in the presence of peripheral neuropathy or renal failure. Think about acute Charcot arthropathy even when deformity is not present or pain is not reported.

  • To confirm the diagnosis of acute Charcot arthropathy, refer the person within 1 working day to the multidisciplinary foot care service for triage within 1 further working day. Offer non‑weight‑bearing treatment until definitive treatment can be started by the multidisciplinary foot care service.

  • National Institute for Health and Care Excellence (NICE)