Diabetes and Feet
Diabetes is the world’s fastest growing chronic condition,1 so it has never been more important to understand the complications and consequences of the diabetic foot. In Australia 12,500 individuals with diabetes are living with a diabetes-related lower limb, foot, and/or toe amputation.2 Professor Stephen Twigg and his team from the Royal Prince Alfred Hospital have recently stated that 85% of these amputations are preventable with the delivery of well-integrated primary and secondary care.3 As diabetes educators and other health professionals, we are well situated in engaging with individuals with diabetes and can make a difference to these numbers.
Role of the diabetes educator
Diabetes educators are well situated to provide education, perform tests and coordinate referrals, ensuring that individuals with diabetes are able to self-care and gain access to services that they may require. The key to reducing diabetes-related amputation is prevention, early diagnosis, and timely access.
Assessments and recommendations that are used by diabetes educators in identifying diabetic foot disease risk are:
Identifying individuals at the highest risk of foot disease, which includes those with a history of foot wounds, minor, and major lower limb amputations, and end-stage renal disease.4 These individuals generally suffer from loss of protective sensation in their feet and/or peripheral arterial disease, which can be quickly screened by health professionals during consultations.
Monofilament testing is a simple tool that can be used to identify an individual’s loss of protective sensation. Using a 10g Semmes-Weinstein monofilament, and applying 10 grams of pressure on the plantar surface of the hallux, 1st, and 5th metatarsophalangeal joint, the undetectable areas indicate the loss of protective sensation of the foot. Individuals living with paresthesia symptoms are recommended to closely monitor their blood glucose levels within normal limits to reduce further nerve damage and seek further advice from their GPs for possible medical management of symptoms.
The palpation of pedal pulses can identify the risk of impaired arterial supply to the feet. The absence of the posterior tibial artery and/or dorsalis pedis on either foot would suggest further investigation is required to identify peripheral arterial disease. If a client reports symptoms of claudication and rest pain this would also be an indicator of peripheral arterial disease (PAD). By referring to podiatrists, further investigations using a hand held doppler or GP referral for an arterial duplex ultrasound can initiate patient access to vascular medical interventions, if required.
The visual inspection of the skin, nails and boney prominences can identify high-risk areas for ulcerations. Corns, callus, fissures, skin maceration, anhidrotic skin, and skin and nail infections are indications for individuals to seek further advice and treatment from a podiatrist. Foot deformities such as a hammer or clawed toes, bunions, and arthritis can cause the boney prominences rubbing in poorly fitting footwear, thus increasing foot ulceration risks. There are many resources that patients and health professionals can access on foot care advice at Diabetes Australia5 and Australian Podiatry Association6.
The identification of an individual’s frequency and regularity of engagement with podiatrists. Regardless of the individual’s ability to provide self-care to their feet, it is important that all individuals living with diabetes are having diabetes foot assessments. The very-low risk individuals, are individuals that have intact protective sensation and adequate arterial supply to their feet, still requiring yearly foot screens.4 The low-risk foot is identified by a loss of protective sensation or impaired arterial supply, and these individuals are recommended to seek screening every 6 to 12 months.4 The moderate-risk foot is identified in individuals with foot deformities in addition to the above low-risk foot risk factors, and are recommended to be screened every 3 to 6 months.4 The high-risk foot is identified in individuals with a history of foot ulcers, minor or major lower limb amputations, end-stage renal disease, including the low and moderate foot risk factors and requires screening every 1 to 2 months.4 Continuous encouragement of client engagement with podiatrists in the recommended time frames can significantly reduce future foot complications and ulcerations.
Access and referrals
For individuals living with diabetes with no foot health risks and who are able to self-care, the recommendations are a yearly foot health screen by their diabetes educators, GPs or podiatrists. They yearly foot check is to monitor the change and risks development in their foot health. When requiring podiatry services, options of private, community, and hospital outpatient services are available. Depending on the individual’s location, determining which facility is more appropriate can be difficult. Most importantly, high-risk foot individuals that have an active wound and Charcot arthropathy need to be promptly referred to an interdisciplinary high-risk foot service.7 However, if the individual has severe systemic infection signs and symptoms, or is undergoing acute limb-threatening ischemia, immediate referral to the emergency department is required.7 For all other podiatry services, it is recommended to refer to private or community podiatry for care.
AUSTRALIAN CLINICAL TRIAGE GUIDE, by Diabetic Foot Australia & Australian Diabetes Society (2020). Available from: https://diabetessociety.com.au/downloads/20200408%20COVID19-Australian-Clinical-Triage-Guide-for-DFD-V1.0.pdf
Basic Foot Care, by Department of Veterans’ Affairs (2020). Available from: https://www.dva.gov.au/sites/default/files/files/providers/cn/dva-pcv-resource-basic-foot-care-may2020.pdf
CORNS AND CALLUSES, by Australian Podiatry Association (2021). Available from: https://www.podiatry.org.au/documents/item/2336
DIABETES & YOUR FEET, by Australian Podiatry Association (2021). Available from: https://www.podiatry.org.au/documents/item/2324
Foot Care, by Diabetes Australia (2021). Available from: https://www.diabetesaustralia.com.au/living-with-diabetes/preventing-complications/foot-care/
FOOT ULCERS – TREATMENT AND MANAGEMENT, by Australian Podiatry Association (2021). Available from: https://www.podiatry.org.au/documents/item/2334
FOOTWEAR HEALTH CHECK, by Australian Podiatry Association (2021). Available from: https://www.podiatry.org.au/documents/item/2325
FUNGAL AND NAIL INFECTIONS, by Australian Podiatry Association (2021). Available from:
INCORRECTLY FITTED SHOES, by Australian Podiatry Association (2021). Available from: https://www.podiatry.org.au/documents/item/2329
Monofilament Testing in the Diabetic Foot, by Canadian Journal of Diabetes (2018). Available from: https://guidelines.diabetes.ca/docs/cpg/Appendix-12.pdf
TOP TIPS TO CARE FOR YOUR FEET, by Australian Podiatry Association (2021). Available from: https://www.podiatry.org.au/documents/item/2333
Diabetes educators are engaged with individuals living with diabetes early and throughout their diagnosis. This well situates diabetes educators to promote the importance of good foot health, education, and access to other health professionals throughout their care. By identifying an individual’s foot health risks and encouraging them to have regular foot checks and timely care, the risk of developing diabetic foot disease can be significantly reduced.
Diabetes globally â Diabetes Australia [Internet]. Diabetesaustralia.com.au. 2021 [cited 15 July 2021]. Available from: https://www.diabetesaustralia.com.au/about-diabetes/diabetes-globally/2.
Diabetes Feet Australia [Internet]. Diabetes Feet Australia. 2021 [cited 15 July 2021]. Available from: https://www.diabetesfeetaustralia.org3.
Twigg S, Wischer N, Frank G. Avoiding Amputations: The Foot Forward Program. 1st ed. Diabetes Australia; 2021.4.
IWGDF Guidelines on the prevention and management of diabetic foot disease [Internet]. 1st ed. 2021 [cited 15 July 2021]. Available from: https://iwgdfguidelines.org/wp-content/uploads/2019/05/IWGDF-Guidelines-2019.pdf5.
Foot care â Diabetes Australia [Internet]. Diabetesaustralia.com.au. 2021 [cited 7 August 2021]. Available from: https://www.diabetesaustralia.com.au/living-with-diabetes/preventing-complications/foot-care/6.
Patient Information – Australian Podiatry Association Ltd [Internet]. Podiatry.org.au. 2021 [cited 22 August 2021]. Available from: https://www.podiatry.org.au/foot-health-resources/patient-information7.
AUSTRALIAN CLINICAL TRIAGE GUIDE [Internet]. 1st ed. 2020 [cited 15 July 2021]. Available from: https://diabetessociety.com.au/downloads/20200408%20COVID19-Australian-Clinical-Triage-Guide-for-DFD-V1.0.pdf