Diabetic foot complications, including ulcers and infections, are a common and costly complication of diabetes mellitus.
Most diabetic foot ulcers are caused by repetitive trauma sustained during activity on a structurally abnormal, insensate foot.
Ulcers act as a portal of entry for bacterial infections. Preventing and/or healing ulcers helps prevent infections and thereby minimises risk of limb loss.
Prevention and identification may be by primary care physicians; however, UK guidance recommends referring all patients with active foot problems to a multidisciplinary diabetic foot care clinic or inpatient unit.
Antibiotics are recommended for management of infection, with associated drainage/debridement of any ongoing deep soft-tissue infection. Amputation is typically reserved for gangrene, loss of limb function, and severe non-reconstructable peripheral arterial disease.
The term 'diabetic foot complications' encompasses the conditions of diabetic foot ulcer (i.e., a break in the skin that includes as a minimum the epidermis and part of the dermis and which occurs below/distal to the malleoli in a person with diabetes) and diabetic foot infections (i.e., any soft-tissue or bone infection occurring in the diabetic foot, including osteomyelitis).
History and exam
Key diagnostic factors
- presence of risk factors
- foot ulcer
- foot pain
- loss of protective sensation
- foot deformity
- fever or chills
Other diagnostic factors
- foot erythema
- oedema of foot, ankle, or calf
- absent pedal pulses
- previous history of foot ulcer
- previous history of amputation
- sensory neuropathy
- peripheral arterial disease
- end-stage renal disease
- Charcot midfoot deformity
- structural forefoot deformities
- limited ankle joint mobility (ankle equinus)
- visual impairment
- poor glycaemic control
1st investigations to order
- blood glucose level
- x-ray foot
Investigations to consider
- microbiological culture
- erythrocyte sedimentation rate
- C-reactive protein
- ankle/toe pressures
- renal function
- MR angiography
- CT angiography
- MRI foot
- arterial duplex ultrasound
- serum procalcitonin
- 18F-fluorodeoxyglucose (FDG)-PET/CT
at initial presentation
after initial definitive treatment
Frances L. Game, MBBCh, FRCPath
Consultant Diabetologist and Clinical Director of R&D
Department of Diabetes and Endocrinology
University Hospitals of Derby and Burton NHS Foundation Trust
FLG is an author of a reference cited in the topic.
Dr Frances L. Game would like to gratefully acknowledge Dr Neal R. Barshes, Dr Joseph L. Mills, and Dr David G. Armstrong, previous contributors to this topic.
NRB and DGA declare that they have no competing interests. JLM is a consultant for, and owns stocks in, Nangio TX; a member of the scientific advisory committees for Cesca, AnGes, and AstraZeneca; and the Co-National Principal Investigator for the Voyager trial of rivaroxaban in peripheral arterial disease patients undergoing intervention (funding for this institutional research grant goes directly to the Baylor College of Medicine).
Simon Ashwell, MBChB, MD, FRCP
Consultant Physician of Diabetes and Endocrinology
Diabetes Care Centre
The James Cook University Hospital
SA declares that he has no competing interests.
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- 2021 evidence-based Australian guidelines for diabetes-related foot disease
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