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
  • Pain (burning)
  • Less sweaty feet
  • 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

Damage to the blood supply
might be shown by:

  • Cramp in the calves (at rest or when walking)
  • Shiny smooth skin
  • Loss of hair on the legs and feet
  • Cold, pale feet
  • Changes in the skin colour of the feet
  • Wounds or sores that do not heal
  • Pain in the foot or feet
  • 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 ?

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

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 perform yourself your patient’s risk assessment, make sure he is referred to the right 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 prevention.

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

Glycemic control

Checking that their blood glucose is within the normal range throughout the day is the first step to prevent ulceration. Keeping their blood glucose within target will help your patients prevent damage to their feet and can stop things getting worse.

Daily foot check

Patients with diabetes should check their feet every day for cuts and wounds. Whether they’re about to put their socks on, or taking them off before bed, have a good look. Any 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. If this is too hard, they could try to get someone else to check it for them, They can also ask their nurse or healthcare professional to do it during their regular checkups.


Remind your patients with diabetes that they should have a foot check at least once a year that’s arranged by their GP practice.

Daily foot care

Your patients with diabetes should wash their feet daily in warm, but not hot water, and dry them properly. Remind them that they have to dry between their toes too. Using moisturising cream will help them keep their skin soft, but they should not apply it between their toes or it may make the skin too moist.

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 allow them room to breathe.
  • Avoid shoes that are too small or pointed at the ends. If their shoes are too tight, too loose or rub them then they should not wear them. Even if they look great.
  • Avoid walking around barefoot.
  • To not wear tight or knee-high socks
  • To examine their shoes, socks and stockings for damage each time before putting them on. Cracks, small stones and nails can irritate and damage their skin.
In case you notice anything unusual during the foot inspection of your patients, remember that…

When it comes to diabetic foot, 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.