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Reduce risk of diabetic foot ulcers through regular foot assessment.
Perform foot assessment in people with diabetes at least once a year. Check feet more frequently for those at a higher risk of diabetic foot ulcers.
Regularly educate people with diabetes on good foot care and appropriate footwear.
2
3
1
Foot assessment in people with diabetes
Key messages
APPROPRIATE CARE GUIDE www.ace-hta.gov.sgPublished: 6 June 2019
Regular foot assessment reduces risk of diabetic foot ulcers
Diabetes is a major global health concern. It is associated with macro- and microvascular complications, including diabetic foot ulcers (DFU). In Singapore, there is an average of four lower extremity amputations (LEA) a day in people with diabetes.1 About 3 in 4 LEA are preceded by DFU.2 In addition to LEA, DFU are associated with mobility loss, poorer quality of life, and decreased overall productivity.3 Regular foot assessment is recommended to identify and manage DFU risk.4,5
In Singapore, there is an average of four amputations a day in people with diabetes.
amputations could be avoided through regular foot assessment.
3About 4out of
Chapter of EndocrinologistsChapter of Neurologists
College of Physicians, Singapore
Chapter of Family Medicine Physicians
Academy of Medicine, Singapore
College of Family Physicians,Singapore
Chapter of General SurgeonsChapter of Orthopaedic SurgeonsCollege of Surgeons, Singapore
Of the factors related to DFU risk identification and management presented in Figure 2, the following are used in risk stratification to determine the risk category:4-9
• Previous foot ulcer or amputation • Chronic kidney disease stage 5 (estimated glomerular filtration rate <15 ml/min/1.73m2)• Examination or test findings of:
Callus Deformity Peripheral arterial disease (PAD) Neuropathy
Figure 3 describes the foot examination and tests in assessing callus, deformity, PAD, and neuropathy.
Foot assessment should be performed at least:• Once a year for patients in the low risk category • Every six months for patients in the moderate risk category• Every three to four months for patients in the high risk category
2
Components of foot assessment include risk stratification, referral, and patient education.
Foot assessment
* This estimate, of low heterogeneity, was derived from a fixed effect meta-analysis of cohort studies extracted from Liu et al. (2017).10
People with diabetes should first be checked for active diabetic foot conditions. If present, patients should be immediately treated or referred (Figure 1).
Referral decisions are informed by various factors, including symptoms of deformity, PAD, or neuropathy (Figure 2). When referring for these symptoms, assign the patient a risk category as though the deformity, PAD, or neuropathy is present and follow up based on the assigned category. If cleared of the factor, reassign a risk category without that factor and manage accordingly.
Advise patients to maintain optimal glycaemic control. Regularly educate them on good foot care and appropriate footwear (Figure 4). Encourage smokers to quit; smoking elevates LEA risk by 37%* in people with diabetes.10
Risk stratification
Referral
Patient education
Figure 1. Active diabetic foot presentation
Refer to emergency department immediately
Treat immediately; refer as needed for timely specialist management
Active diabetic foot conditions
• Signs of inflammation, infection, or acute Charcot arthropathy, such as redness, swelling, or warmth
• Cellulitis or pus from wound
• Wet gangrene
• Tissue loss (ulcer or blister)
• Dry gangrene
Referral example
A patient referred for symptoms of PAD should be deemed to have the PAD risk factor (until proven otherwise by the vascular specialist). If no other factor is present, this patient should be assigned the moderate risk category and be followed up in no later than six months’ time.
At the next appointment, reassess feet and review vascular input to stratify the patient’s risk accordingly.
3
Prev
ious
fo
ot u
lcer
or
ampu
tatio
n
OR
CKD
sta
ge
5 (e
GFR
<
15 m
l/ m
in/1
.73m
2 )
Def
orm
ity
Def
orm
ity,
incl
udin
g:
• C
harc
ot
arth
ropa
thy
• H
allu
x va
lgus
(b
unio
n)
• H
amm
er o
r cl
aw t
oe
if it
incr
ease
s ru
bbin
g in
fo
otw
ear
or
pres
sure
PAD
Neu
rop
athy
Inab
ility
to fe
el 1
0 g
mon
ofila
men
t at a
ny o
f the
eig
ht
test
ed s
ites.
Thi
s in
dica
tes
loss
of
pro
tect
ive
sens
atio
n.
OR
Inab
ility
to
feel
vib
ratio
n fu
lly f
rom
act
ivat
ed 1
28 H
z tu
ning
fork
, as
asse
ssed
by
exam
iner
. Thi
s in
dica
tes
loss
of
vib
ratio
n pe
rcep
tion.
OR
Inab
ility
to
feel
vib
ratio
n fr
om
neur
othe
siom
eter
pro
be a
t ≤2
5 V
(ave
rage
). Th
is in
dica
tes
loss
of
vibr
atio
n pe
rcep
tion.
Abs
ence
of
any
peda
l pul
se
with
eith
er A
BP
I ≤0.
9 or
toe
pr
essu
re <
60 m
mH
g:
Abs
olut
e sy
stol
ic
toe
pres
sure
<
60 m
mH
g is
as
soci
ated
with
im
paire
d w
ound
he
alin
g.11
Wor
k is
ong
oing
to
det
erm
ine
a lo
cally
-der
ived
to
e pr
essu
re
valu
e sp
ecifi
cally
fo
r DFU
risk
st
ratifi
catio
n.
AB
PI ≤
0.9
indi
cate
s im
paire
d ar
teria
l blo
od
flow
.
AB
PI >
0.9
in
peop
le w
ith
diab
etes
doe
s no
t exc
lude
PA
D, a
s it
coul
d be
a
fals
e el
evat
ion.
Figu
re 2
. Foo
t ass
essm
ent i
n pe
ople
with
dia
bete
s(F
or fe
atur
es o
f act
ive
diab
etic
foot
con
ditio
ns, s
ee F
igur
e 1)
Clinical findings Risk-based management
Foo
t ex
amin
atio
n a
nd
tes
ts†
Pati
ent
edu
cati
on
Non
e
OR
Sim
ple
callu
s
Ass
ess
at le
ast
once
a y
ear
Ref
er t
o s
pec
ialis
t o
r p
od
iatr
y as
nee
ded
Thic
k ca
llus
requ
iring
tre
atm
ent
OR
Def
orm
ity
with
sim
ple
callu
s or
thi
ck
callu
s re
quiri
ng t
reat
men
t
OR
One
of:
• D
efor
mity
•
PAD
•
Neu
ropa
thy
Ass
ess
at le
ast
ever
y si
x m
onth
s
LOW
RIS
KM
OD
ER
AT
E R
ISK
HIG
H R
ISK
Pre
viou
s fo
ot u
lcer
or
ampu
tatio
n
OR
CK
D s
tage
5 (e
GFR
<15
ml/m
in/1
.73m
2 )
OR
Cal
lus
with
intr
ader
mal
ble
edin
g
OR
Two
or m
ore
of:
• D
efor
mity
or
any
callu
s•
PAD
• N
euro
path
y Ass
ess
at le
ast
ever
y th
ree
to f
our
mon
ths
Cal
lus,
in
clud
ing:
• Si
mpl
e ca
llus
• Th
ick
callu
s re
quiri
ng
trea
tmen
t
• C
allu
s w
ith
intr
ader
mal
bl
eedi
ng
Def
orm
ity
Pain
or
func
tiona
l im
pairm
ent
beca
use
of
defo
rmity
PAD
Neu
rop
athy
Sev
ere
or
wor
seni
ng
sym
ptom
s,
such
as
num
bnes
s,
pain
, or
tingl
ing
sens
atio
n,
with
out
findi
ngs
sugg
estiv
e of
PA
D
Any
of
the
follo
win
g:
• R
est
pain
• Va
scul
ar
clau
dica
tion
• S
ever
e or
w
orse
ning
sy
mpt
oms
of
neur
opat
hy,
with
find
ings
su
gges
tive
of P
AD
Oth
ers
Furt
her
ref
erra
l co
nsi
der
atio
ns
Cha
rcot
art
hrop
athy
as
sug
gest
ed b
y cl
inic
al o
r X
-ray
fin
ding
s, s
uch
as
mid
foot
col
laps
e,
join
t des
truc
tion,
jo
int s
ublu
xatio
n,
or m
alal
ignm
ent
Feat
ure
s su
gg
esti
ng
at
ypic
al f
orm
s o
f d
iab
etic
n
euro
pat
hy o
r ca
use
s o
f n
euro
pat
hy o
ther
th
an
dia
bet
es, s
uch
as
acu
te
on
set,
asy
mm
etri
cal
dist
ribu
tion,
or
mot
or d
efici
ts
wor
se th
an s
enso
ry d
efici
ts12
Co
rn, c
allu
s,
def
orm
ity, o
r p
ath
olo
gic
al
toen
ail
nee
din
g
man
agem
ent
Ref
er t
o
ort
ho
pae
dic
sR
efer
to
va
scu
lar
Ref
er t
o
neu
rolo
gy
Ref
er t
o
po
dia
try
Ref
erra
l as
nee
ded
Sym
pto
ms
• G
lyca
emic
co
ntro
l
• S
mok
ing
hist
ory
• Fo
ot c
are
• Fo
otw
ear
• S
kin
inte
grity
• To
enai
l
AB
PI, a
nkle
-bra
chia
l pre
ssur
e in
dex;
CK
D, c
hron
ic k
idne
y di
seas
e; D
FU, d
iabe
tic fo
ot u
lcer
s;
eGFR
, est
imat
ed g
lom
erul
ar fi
ltrat
ion
rate
; PA
D, p
erip
hera
l art
eria
l dis
ease
† D
iagn
osis
of P
AD
or n
euro
path
y (if
ava
ilabl
e) c
ould
als
o be
use
d fo
r DFU
risk
str
atifi
catio
n.
Exam
inat
ion
and
test
find
ings
of P
AD
and
neu
ropa
thy
show
n he
re a
re fo
r the
pur
pose
of
DFU
ris
k st
ratifi
catio
n, a
nd m
ay n
ot b
e di
agno
stic
of P
AD
or
neur
opat
hy.
Ris
k st
rati
fica
tio
n
Med
ical
H
isto
ry
See ‘Referral’ on page 2
Figu
re 3
. Foo
t exa
min
atio
n an
d te
sts
in ri
sk s
tratifi
catio
n fo
r dia
betic
foot
ulc
ers
Deformity
• In
spec
t bo
th f
eet
thor
ough
ly b
y ex
amin
ing
skin
inte
grit
y, e
spec
ially
are
as w
ith
callu
s or
def
orm
ity.
• Lo
ok f
or d
efor
mit
y th
at in
crea
ses
rubb
ing
in f
ootw
ear
or p
ress
ure.
Ham
mer
toe
Hal
lux
valg
usC
allu
s
Neuropathy
10 g
mon
ofila
men
t (p
refe
rred
tes
t)12
8 H
z tu
ning
for
k
Neu
roth
esio
met
er
PAD
• P
alpa
te p
edal
pu
lses
(dor
salis
ped
is a
nd p
oste
rior
tibia
l) on
eac
h fo
ot.
• If
any
ped
al p
ulse
is a
bsen
t:
Obt
ain
ankl
e-b
rach
ial p
ress
ure
ind
ex (
AB
PI)
of
eac
h fo
ot: m
easu
re s
ysto
lic a
nkle
pre
ssur
e of
eac
h fo
ot; m
easu
re s
ysto
lic b
rach
ial p
ress
ure
of e
ach
arm
; div
ide
each
ank
le p
ress
ure
by t
he
grea
ter
of t
he t
wo
brac
hial
pre
ssur
es.
O
btai
n ab
solu
te
syst
olic
to
e p
ress
ure
of
eac
h bi
g to
e.
OR
Post
erio
r tib
ial
Toe
pres
sure
AB
PI
Dor
salis
ped
is
• A
sk p
atie
nt t
o cl
ose
both
eye
s.
• A
pply
pre
ssur
e w
ith a
10
g m
on
ofi
lam
ent
on b
ack
of p
atie
nt’s
han
d un
til it
bu
ckle
s. T
his
will
be
the
base
line
sens
atio
n fo
r su
bseq
uent
com
paris
on.
•Assessplantarregionoffirst,third,andfifthmetatarsalheads,andthebigtoe
of e
ach
foot
— a
tot
al o
f ei
ght
site
s fo
r bo
th f
eet.
Ask
pat
ient
to
info
rm e
xam
iner
w
hene
ver
pres
sure
is f
elt.
• P
lace
the
neu
roth
esio
met
er p
robe
at
the
dist
al t
ip o
f ea
ch b
ig t
oe.
• B
egin
at
0 V,
incr
easi
ng v
olta
ge g
radu
ally
unt
il pa
tient
feel
s vi
brat
ion.
• Ta
ke t
hree
mea
sure
men
ts a
nd a
vera
ge t
he r
eadi
ngs.
• A
sk p
atie
nt t
o cl
ose
both
eye
s.
• P
lace
an
activ
ated
128
Hz
tun
ing
fork
ove
r th
e in
terp
hala
ngea
l joi
nt o
f ea
ch b
ig t
oe.
• A
sk p
atie
nt t
o in
form
exa
min
er w
hen
vibr
atio
n is
no
long
er f
elt.
OR
OR
PAD
, per
iph
eral
art
eria
l dis
ease
4
5
Figure 4. Patient education aid on foot care and footwear(This aid is designed to complement, and not replace, education or advice provided by a healthcare professional)
Foot care
• Clean feet daily with mild soap and water
• Dry thoroughly between each toe
• Use a pumice stone or foot file to gently remove hard skin
• Avoid cutting nails too short; cut them straight across and file corners
Maintain good foot care and hygiene
• Avoid using harsh soap
• Apply moisturiser daily but not between each toe
• Avoid scratching skin as it may lead to wound or bleeding
Moisturise regularly
• Clean small wound with saline before applying antiseptic and covering with a plaster
• Seek medical help if there is no improvement after two days or if there are signs of infection
Apply simple first aid for small wound
• Wear well-fitting covered shoes with socks
• Home sandals are recommended
• Check and remove any stones or sharp objects inside shoes before wearing them
Wear well-fitting and covered footwear
If signs of infection are present, such as redness, swelling, increased pain, pus, fever, or the wound starts to smell, seek medical help as soon as possible
Seek medical help if wound is not healing well, or worsens
Footwear
For better comfort
Soft cushioning inner sole
To support middle part of the foot (arch)
Firm at back and middle sections of the sole
Low heel
Firm back (heel counter)
To allow natural movement of toes when walking
Flexible at front section of the sole
To hold feet in place and reduce rubbing within shoes
Adjustable ankle fastening (lace or velcro)
• To let toes wiggle freely
• Make sure shoes are broad enough for feet and any deformities
• Make sure there is one thumb’s width of space between toes and tip of the shoes
Deep and wide toe box
To prevent too much moisture within shoes
Soft and breathable materials
Watch out for:
• Blister, wound, corn, callus, or toenail abnormality
• Redness, swelling, bruise, or increased warmth
Monitor feet every day
1. Ministry of Health, Singapore. Lower extremity amputation, including toe amputation, in people with diabetes. 2016. Unpublished.
2. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care. 1990;13(5):513-521.
3. Vileikyte L. Diabetic foot ulcers: a quality of life issue. Diabetes Metab Res Rev. 2001;17(4):246-249.
4. Bus SA, Lavery LA, Monteiro-Soares M, et al.; International Working Group on the Diabetic Foot. IWGDF guideline on the prevention of foot ulcers in persons with diabetes. 2019. Available from: https://iwgdfguidelines.org/wp-content/uploads/2019/05/02-IWGDF-prevention-guideline-2019.pdf [Accessed 27 May 2019].
5. National Institute for Health and Care Excellence (NICE). Diabetic foot problems: prevention and management. 2016. NICE clinical guideline 19.
6. American Diabetes Association. 11. Microvascular complications and foot care: standards of medical care in diabetes 2019. Diabetes Care. 2019;41(Suppl 1):S124-S138.
7. Embil JM, Albalawi Z, Bowering K, et al.; Diabetes Canada Clinical Practice Guidelines Expert Committee. Foot care. Can J Diabetes. 2018;42(Suppl 1):S222-S227.
8. Scottish Intercollegiate Guidelines Network (SIGN). Management of diabetes. 2017. SIGN publication no. 116.
9. Hingorani A, LaMuraglia GM, Henke P, et al. The management of diabetic foot: a clinical practice guideline by the Society of Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg. 2016;63(Suppl 2):3S-21S.
10. Liu M, Zhang W, Yan Z, et al. Smoking increases the risk of diabetic foot amputation: A meta-analysis. Exp Ther Med. 2018;15(2):1680-1685.
11. Andersen CA. Noninvasive assessment of lower-extremity hemodynamics in individuals with diabetes mellitus. J Vasc Surg. 2010;52(Suppl 3):76S-80S.
12. Pop-Busui R, Boulton AJ, Feldman EL, et al. Diabetic neuropathy: a position statement by American Diabetes Association. Diabetes Care. 2017;40(1):136-154.
Expert Group
Chairpersons
Dr Elaine Tan (NHGP)
Dr Julian Wong (NUHCS)
Group members
Dr David Carmody (SGH)
Dr Sadhana Chandrasekar (TTSH)
Dr Chan Yee Cheun (NUH)
Dr Cheah Ming Hann (NUP)
Ms Chioh Mei Suang (AIC)
Ms Foo Mei Ching (SHP)
Ms Chelsea Law Chiew Chie (KTPH)
A/Prof Inderjeet Singh Rikhraj (SGH)
Dr Donna Tan Mui Ling (NHGP)
Mr Tan Liang Sheng (NUP)
Dr Derek Tse Wan Lung (SHP)
Dr Theresa Yap
(Yang & Yap Clinic & Surgery)
Ms Yeo Loo See (NHGP)
References
About the Agency
The Agency for Care Effectiveness (ACE) is the national health technology assessment agency in Singapore residing within the Ministry of Health (MOH). ACE develops evidence-based “Appropriate Care Guides” or ACGs to guide a specific area of clinical practice. ACGs are aimed at complementing MOH Clinical Practice Guidelines when these are available, by providing additions and updates as reflected in the evidence at the time of development, and incorporating cost-effectiveness considerations where relevant. The ACGs are not exhaustive of the subject matter. When using the ACGs, the responsibility for making decisions appropriate to the circumstances of the individual patient remains with the healthcare professional. This ACG will be reviewed 3 years after publication, or earlier, if new evidence emerges that requires substantive changes to the recommendations.
Find out more about ACE at www.ace-hta.gov.sg/about
© Agency for Care Effectiveness, Ministry of Health, Republic of SingaporeAll rights reserved. Reproduction of this publication in whole or in part in any material form is prohibited without the prior written permission of the copyright holder. Application to reproduce any part of this publication should be addressed to:
Agency for Care EffectivenessEmail: [email protected]
In citation, please credit the “Ministry of Health, Singapore”,when you extract and use the information or data from the publication.
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