To address the growing problem of diabetic foot care, the Society for Vascular Surgery has collaborated with the American Podiatric Medical Association and the Society for Vascular Medicine to develop a clinical practice guideline for the care of feet in people with diabetes.
The guidelines are US-focused, but the recommendations are representative of the body of evidence relating to diabetic foot care, and may therefore have global relevance.
What does the panel recommend?
The guidelines divide diabetic foot care into five key areas: prevention of diabetic foot ulceratio, off-loading, diagnosis of osteomyelitis and peripheral arterial disease.
Part one
Part one of the guidelines concern the prevention of diabetic foot ulceration. The guidelines recommend firstly that all diabetes patients have their feet inspected by physicians or practitioners trained to provide foot care. If the patients feet are normal, these checks are to be repeated once per year. If the feet show signs of peripheral neuropathy, the checks are to be repeated twice a year. Should the patient have neuropathy plus a deformity or peripheral arterial disease, they should be re-examined quarterly. In patients who have previously had an ulcer or amputation, the checks should be quarterly or monthly.
The guidelines also recommend that patients and their families be provided with education about foot care. The education “can be provided by a physician, podiatrist, or skilled health care practitioner providing dedicated education time to explain the basic of the care of the foot, callus, and nail and fitting of shoes.” This measure is described in the guidelines as “likely cost-effective.”
The first part of the guidelines also recommends that only people at high risk of foot ulcers should be given custom therapeutic footwear. In patients with average risk, this is unnecessary.
Part one concludes by recommending on-target glycemic control as the basic method of preventing foot ulcers.
Part two
Part two discusses the best methods for taking the pressure of a diabetic foot ulcer. In patients with a plantar foot ulcer – that is, an ulcer on the sole of foot caused by repeated injury – the researchers recommend using a total contact cast (TCC) or fixed ankle walking boot, which cannot be removed.
In patients whose ulcer in non-plantar, the guidelines recommend a surgical sandal or heel relief shoe.
People with diabetes who healed a previous foot ulcer should be provided with therapeutic footwear which has insoles to relieve pressure.
Part three
Part three looks at oestomyelitis, which is inflammation of the bone or bone marrow. It is most commonly caused by infection. It can occur in people with diabetic foot problems. This part of the guidelines is largely technical, and relevant mainly to healthcare professionals.
Part four
Part four covers how to care for wounds in people with diabetic foot ulcers. The guidelines recommends frequent evaluation one to four week intervals. At these evaluations, the foot wound should be measured in order to monitor wound size and healing progress.
Part five
The final part of the guidelines suggest that people with diabetes should receive ankle brachial index tests, which are used to measure peripheral artery disease. People with diabetes who have previously developed foot ulcers are recommended to have an annual examination of their lower legs and feet.
People with a foot ulcer who also have peripheral artery disease should have either surgical bypass or endovascular therapy, the guidelines suggest.
Going forward
“Whereas these guidelines have addressed the five key areas in the care of [diabetic foot ulcers], they do not cover all the aspects of this complex condition,” the authors wrote. “Going forward as future evidence accumulates, we plan to update our recommendations accordingly.”
The guidelines are published in the Journal of Vascular Surgery.

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