Diabetic Foot Disease
Risk stratification and foot score
Care of people at low current risk
Care of people at increased risk
Care of people with foot care emergencies
General Management Approach
• Effective care involves a partnership between patients and professionals and all decision making should be shared
• Arrange a recall and annual review system for all individuals
• As part of annual review, competent trained personnel should examine feet to detect risk factors for ulceration
• If the patient is already seeing a podiatrist from Carmarthenshire NHS Trust, a copy of the foot assessment form should have been forwarded to you. If this is the case, enter the details from this form into your diabetic record, and there is no need to repeat the foot examination, unless the patient feels their feet have changed in some way since that assessment (an example of this form is included below).
• In the UK , there is currently no official recognition process for podiatry. Anybody with very limited training can set themselves up as a private podiatrist. It is therefore recommended that if the patient is seeing a private podiatrist, the full annual foot review be completed as usual.
• Examination of feet should include:
• Testing of foot sensation using a 10g monofilament or calibrated vibration (Rydell-Seiffer C64 Fixed weight tuning fork)
• Palpation of foot (Dorsalis pedis) and ankle (Posterior tibial) pulses
• Inspection of foot shape to identify any:
• Foot deformity
• Joint rigidity
• Skin condition such as callus
• Ulceration
• Oedema
• Skin fragility
• Appropriate footwear
• History of foot problems since last review
• Visual and mobility problems preventing self care of feet
• Self care behaviours and knowledge of foot care (including carer if appropriate)
• Classify after assessment foot risk as
- low risk
- increased risk
- high risk
- ulcerated foot
• Monitor related factors (blood glucose control, claudication, drug therapy, smoking, social deprivation)
Risk stratification and foot score
Allocate the following scores for abnormal findings. The score from each foot should be added to give the final score.
Feature |
Finding |
Score |
Pulses |
One pulse absent Both pulses absent |
5 10 |
Sensation |
Either Vibration perception absent in big toe Vibration perception absent in mid foot Vibration perception absent in ankle Or Monofilament perception absent in one area Monofilament perception absent in two areas Monofilament perception absent in all 3 areas |
10 15 20
10 15 20 |
Symptoms/Inspection |
Neuropathic symptoms Claudication <200 meters Skin cracks, corns or calluses Foot deformity or bony prominence Foot ulcer, present or past Previous lower limb or digit amputation Visual acuity in both eyes 6/12 or less |
10 10 5 5 25 25 10 |
Score 0-5 - Low Risk
Score 10-20 - Increased Risk
Score 25 or more - High Risk
Care of people at current low risk
(normal sensation, palpable pulses, and no foot deformity)
• To improve knowledge, encourage beneficial self-care and minimize inadvertent self- harm, healthcare professionals should discuss and agree a management plan including foot care education with each person (see leaflet section- Care of the Feet: Low Risk).
Care of people at increased risk
(neuropathy or absent pulses or other risk factor)
• Refer for Podiatry Review
• Inspect feet 3 - 6 monthly
• Review need for vascular assessment
• Patients with risk factors for ulceration should have their footwear evaluated and given appropriate advice
• Enhance foot care education (see leaflet section- Care of feet: High Risk)
NB. If previous foot ulcer or deformity or skin changes manage as high risk (see below)
Care of people at high risk
(neuropathy or absent pulses and deformity or skin changes, or previous ulcer)
Refer for Podiatry Review
• Arrange frequent review (1 - 3 monthly) by community diabetes foot care team
• At each review:
• Inspect feet
• Review need for vascular assessment
• At each review, evaluate provision of and provide
• intensified foot care education, (see leaflet section- Care of feet: High Risk
• specialist footwear and insoles,
• skin and nail care.
• Ensure special arrangements for those people with disabilities or mobility
Care of people with foot care emergencies
• Foot ulceration is usually preventable
• Refer patients to specialised podiatry / high risk foot care team within 24 hours if any of the following occur:
• New ulceration
• New swelling
• Discolouration (redder, bluer, paler, blacker, on part or all of the foot)
• Expect that team to, as a minimum:
• Investigate and treat vascular insufficiency
• Initiate and supervise wound management, using dressings and debridement as indicated
• Use systemic antibiotic therapy for cellulitis or bone infection as indicated (usually staphylococcal coverage, plus wider spectrum, anaerobes, or streptococcal as specifically indicated).
• Ensure an effective means of distributing foot pressures, including specialist footwear, orthotics and casts
• Try to achieve optimal glucose and cardiovascular risk control
Amputation, even if foot ulceration occurs, is nearly always preventable. Reserve amputation for:
• Uncontrolled pain
• Debilitating, long term, non healing ulceration
• Disabling, life threatening infection or Charcot foot.
Your local podiatry service
• New patients at increased risk or high risk are seen within 3 months of referral being received by Carmarthenshire NHS Trust Podiatry Department or sooner if an urgent request is made. A full assessment of the patient is undertaken, i.e. medical history, podiatric pathologies including neurovascular assessment and evaluation of footwear.
• Treatment plan is devised and the patient is offered appointment in appropriate hospital or community clinics with follow up appointments according to need.
• Copy of results of annual review and treatment plan forwarded to GP and to Diabetic Consultant if appropriate.
Podiatry is provided locally across Carmarthenshire from the following sites:
Location |
Time of clinic |
Priory Day Hospital, WWGH |
Monday pm Wednesday pm |
Green Suite (OPD), PPH |
Wednesday pm |
Llandovery Hospital |
|
Amman Valley Hospital |
|
Cross Hands Community Health Clinic |
|
Elizabeth Williams Community Health Clinic,Llanelli |
|
Pond Street Community Health Clinic, Carmarthen |
|
Burry Port Health Centre |
|
Margaret Street Surgery, Ammanford |
|
Brynteg Syrgery, Ammanford |
|
Meddygfa Teilo, Llandeilo |
|
Llanybydder Day Center |
|
Teifi Surgery, Llandyssul |
|
Meddygfa Emlyn, Adpar, NCE |
|
Meddygfa Taf, Whitland |
|
Coach and Horses Surgery, St Clears |
|
Meddygfa Sarn, Pontiets |
|
Pontyberem Community Centre |
|
Meddygfa Minafon, Kidwelly |
|
Adfer Medical Practice |
|
Park Surgery, Llangennech |
|
Referral Guidelines
Patients with foot problems should be referred as follows:
Newly diagnosed at Increased Risk:
• Via Standard Podiatry Referral Form (example attached)
Newly diagnosed High Risk:
• Via Standard Podiatry Referral Form identifying High Risk Assessment or by Letter or Telephone to Diabetic Foot Clinic
Ulceration/ Emergency Care:
• Via urgent telephone call to Foot Ulcer Clinic, Specialist Podiatrist (Diabetes), Diabetic Nurse Specialist or Diabetic Physician.
Gangrene or Rest Pain:
• Via urgent referral to the vascular team
Self Referral by the Patient
• Patients may refer themselves for podiatry if they have diabetes or a variety of other conditions. Click on the following to access the Podiatry Self Referral Form
Contact Addresses
Podiatry Department,
West Wales General Hospital ,
Carmarthen . SA31 2AF. 01267 227058
Podiatry Department,
Prince Philip Hospital ,
Llanelli, SA14 8QT 01554 783266