diabetic foot ulcer cases…1

Up to85%

of lower extremity amputations…2

…could be

1. Boulton AJM. The diabetic foot. Diabet Med 2006;34:87-90

2. International Diabetes Federation Atlas – 9th edition 2019: page 89.


Early identification of at risk patients is key to effectively prevent diabetic foot complications

There are two major risk factors for patients with diabetes :

1Loss of Protective Sensation (LOPS) due to neuropathy
2Peripheral Artery Disease (PAD)

These need to be identified and monitored appropriately to minimise the risk of patients with diabetes developing a Diabetic Foot Ulcer. A daily foot check will help spot any foot problems.

Learn about foot ulceration
These are the main symptoms of LOPS and PAD:

Damage to the nerves (LOPS)
might be shown by:

  • Tingling sensation or pins and needles, painful neuropathy
  • Pain (burning)
  • Less sweaty feet, Anhydrosis, dry feet and fissures especially around the heels
  • Changes in the colour of the feet
  • Changes in the shape of the feet
  • Blisters and cuts
  • Loss of feeling in the feet or legs i.e. parathesia, hyperaesthesia

Damage to the blood supply
might be shown by:

  • Cramp in the calves (at rest or when walking). Intermittent claudication
  • Shiny smooth skin
  • Loss of hair on the legs and feet
  • Cold, pale feet or cyanosis
  • Changes in the skin colour of the feet
  • Wounds or pressure sores that do not heal
  • Pain in the foot or feet e.g. Ischaemic rest pain – especially at night
  • Swollen feet

It is key to identify if these risk factors are present in your patients with diabetes


Depending on the presence of these risk factors we can classify the patients by level of risk and take the appropriate prevention steps.

What is my patient’s level of risk of developing a Diabetic Foot Ulcer (DFU) ?

There is an international classification to categorise the level of risk of your patients.
In addition, it is extremely important to identify a the level of risk of each patient with diabetes regularly. The criteria are very simple: LOPS, PAD, foot deformities, or past history of foot ulceration or lower-extremity amputation. Or end-stage renal disease.
This classification will provide you with the monitoring frequency required for each case, and the recommended specialist level of care.

Ulcer risk

Very low


No LOPS and No PAD, No History of ulceration / non traumatic lower limb amputation, or revascularization

Professionnals, Monitoring frequency

Once a year

Ulcer risk




Professionnals, Monitoring frequency

Once every 6-12 months

Specialist level of care recommended

General practitioner, podiatrist, diabetes nurse

Ulcer risk



LOPS + footdeformity or
PAD + footdeformity

Professionnals, Monitoring frequency

Once every 3-6 months

Specialist level of care recommended

Diabetologist, surgeon (general, orthopedic or foot), vascular specialist, podiatrist, diabetes nurse

Ulcer risk



LOPS or PAD and one or more of the following :

  • History of a foot ulcer
  • A lower-extremity amputation (minor or major)
  • End-stage renal disease
Professionnals, Monitoring frequency

Once every 1-3 months

Specialist level of care recommended

Multi-disciplinary team specialized in diabetic foot care

It is very important to reassess the level of risk of your patients with the recommended frequency in the classification. In case you can’t provide diabetic foot risk assessment, make sure your patient is referred to the appropriate healthcare professional.

In addition to regular risk assessment of your patient, it is key to look at the feet of your diabetes patient at each consultation.
Make the most of each consultation with your patients by educating them on diabetic foot complications prevention.

There are 4 steps you can teach your patients to keep their feet safe and prevent foot ulceration

Glycemic control

Ensuring that their blood glucose is within the normal range throughout the day is the first step to prevent ulceration. Regulating their blood glucose within target will help your patients prevent or delay the progression of diabetic neuropathy and ischemia and ultimately preventing diabetic foot complications.

Daily foot check

Patients with diabetes should check their feet every day for cuts and wounds. Advise your patient to have a look at their feet when they put their socks and shoes on, or when they take them off. Any abnormal changes, and they should see a healthcare professional straight away. If they struggle to lift their feet up, then they might want to use a mirror the see the soles of their feet or seek help from family to check it for them. Any healthcare professional can perform a foot check during regular checkups.


Remind your patients with diabetes that they should have a foot check at least once a year and arrange or refer to dedicated healthcare professional when appropriate.

Daily foot care

Your patients with diabetes should wash their feet daily in warm and dry them properly. Remind them to dry between their toes. Using emollient on legs and feet will help them prevent fissure from anhidrosis. Discourage the use of emollient between their toes or it may macerate and fissure between toes. Discourage hot water foot bath or steaming foot massage, these will cuase burn when diabetic neuropathy is unnoticed.

Appropriate footwear

When it comes to footwear, this is what your patients with diabetes should know:

  • To wear flat shoes that support their feet and accommodate their toes and foot deformity. Always check with hands examining the shoe size as potential insensate feet.
  • Avoid shoes that are too small or pointed at the ends. Feel the shoes with hands, if their shoes are too tight, too loose or rubbing their feet then they should not wear them. Even if they look great.
  • Avoid walking around barefoot.
  • Discourage wearing nylon socks or tight socks. Encourage wearing light colour cotton socks for easy inspection.
  • Advise your patient to examine their shoes, socks and stockings for damage or foreign objects each time before putting them on. Cracks, foreign bodies such as broken glass, small stones and nails inside their shoes can irritate and damage their skin and cause a DFU.
In case you notice anything unusual during the foot inspection of your patients, remember that…

When it comes to diabetic foot complications, every day counts

1. Boulton AJM. The diabetic foot. Diabet Med 2006;34:87-90

2. International Diabetes Federation Atlas – 9th edition 2019: page 89.

3. IWGDF Practical Guidelines – The IWGDF Risk Stratification System and corresponding foot screening frequency – 2019: page 7.