Reduce risk of diabetic foot ulcers through regular foot assessment.

Perform foot assessment in people with diabetes at least once a year. Check feet more frequently for those at a higher risk of diabetic foot ulcers.

Regularly educate people with diabetes on good foot care and appropriate footwear.

2

3

1

Foot assessment in people with diabetes

Key messages

APPROPRIATE CARE GUIDE www.ace-hta.gov.sgPublished: 6 June 2019

Regular foot assessment reduces risk of diabetic foot ulcers

Diabetes is a major global health concern. It is associated with macro- and microvascular complications, including diabetic foot ulcers (DFU). In Singapore, there is an average of four lower extremity amputations (LEA) a day in people with diabetes.1 About 3 in 4 LEA are preceded by DFU.2 In addition to LEA, DFU are associated with mobility loss, poorer quality of life, and decreased overall productivity.3 Regular foot assessment is recommended to identify and manage DFU risk.4,5

In Singapore, there is an average of four amputations a day in people with diabetes.

amputations could be avoided through regular foot assessment.

3About 4out of

Chapter of EndocrinologistsChapter of Neurologists

College of Physicians, Singapore

Chapter of Family Medicine Physicians

Academy of Medicine, Singapore

College of Family Physicians,Singapore

Chapter of General SurgeonsChapter of Orthopaedic SurgeonsCollege of Surgeons, Singapore

Of the factors related to DFU risk identification and management presented in Figure 2, the following are used in risk stratification to determine the risk category:4-9

• Previous foot ulcer or amputation • Chronic kidney disease stage 5 (estimated glomerular filtration rate <15 ml/min/1.73m2)• Examination or test findings of:

Callus Deformity Peripheral arterial disease (PAD) Neuropathy

Figure 3 describes the foot examination and tests in assessing callus, deformity, PAD, and neuropathy.

Foot assessment should be performed at least:• Once a year for patients in the low risk category • Every six months for patients in the moderate risk category• Every three to four months for patients in the high risk category

2

Components of foot assessment include risk stratification, referral, and patient education.

Foot assessment

* This estimate, of low heterogeneity, was derived from a fixed effect meta-analysis of cohort studies extracted from Liu et al. (2017).10

People with diabetes should first be checked for active diabetic foot conditions. If present, patients should be immediately treated or referred (Figure 1).

Referral decisions are informed by various factors, including symptoms of deformity, PAD, or neuropathy (Figure 2). When referring for these symptoms, assign the patient a risk category as though the deformity, PAD, or neuropathy is present and follow up based on the assigned category. If cleared of the factor, reassign a risk category without that factor and manage accordingly.

Advise patients to maintain optimal glycaemic control. Regularly educate them on good foot care and appropriate footwear (Figure 4). Encourage smokers to quit; smoking elevates LEA risk by 37%* in people with diabetes.10

Risk stratification

Referral

Patient education

Figure 1. Active diabetic foot presentation

Refer to emergency department immediately

Treat immediately; refer as needed for timely specialist management

Active diabetic foot conditions

• Signs of inflammation, infection, or acute Charcot arthropathy, such as redness, swelling, or warmth

• Cellulitis or pus from wound

• Wet gangrene

• Tissue loss (ulcer or blister)

• Dry gangrene

Referral example

A patient referred for symptoms of PAD should be deemed to have the PAD risk factor (until proven otherwise by the vascular specialist). If no other factor is present, this patient should be assigned the moderate risk category and be followed up in no later than six months’ time.

At the next appointment, reassess feet and review vascular input to stratify the patient’s risk accordingly.

3

Prev

ious

fo

ot u

lcer

or

ampu

tatio

n

OR

CKD

sta

ge

5 (e

GFR

<

15 m

l/ m

in/1

.73m

2 )

Def

orm

ity

Def

orm

ity,

incl

udin

g:

• C

harc

ot

arth

ropa

thy

• H

allu

x va

lgus

(b

unio

n)

• H

amm

er o

r cl

aw t

oe

if it

incr

ease

s ru

bbin

g in

fo

otw

ear

or

pres

sure

PAD

Neu

rop

athy

Inab

ility

to fe

el 1

0 g

mon

ofila

men

t at a

ny o

f the

eig

ht

test

ed s

ites.

Thi

s in

dica

tes

loss

of

pro

tect

ive

sens

atio

n.

OR

Inab

ility

to

feel

vib

ratio

n fu

lly f

rom

act

ivat

ed 1

28 H

z tu

ning

fork

, as

asse

ssed

by

exam

iner

. Thi

s in

dica

tes

loss

of

vib

ratio

n pe

rcep

tion.

OR

Inab

ility

to

feel

vib

ratio

n fr

om

neur

othe

siom

eter

pro

be a

t ≤2

5 V

(ave

rage

). Th

is in

dica

tes

loss

of

vibr

atio

n pe

rcep

tion.

Abs

ence

of

any

peda

l pul

se

with

eith

er A

BP

I ≤0.

9 or

toe

pr

essu

re <

60 m

mH

g:

Abs

olut

e sy

stol

ic

toe

pres

sure

<

60 m

mH

g is

as

soci

ated

with

im

paire

d w

ound

he

alin

g.11

Wor

k is

ong

oing

to

det

erm

ine

a lo

cally

-der

ived

to

e pr

essu

re

valu

e sp

ecifi

cally

fo

r DFU

risk

st

ratifi

catio

n.

AB

PI ≤

0.9

indi

cate

s im

paire

d ar

teria

l blo

od

flow

.

AB

PI >

0.9

in

peop

le w

ith

diab

etes

doe

s no

t exc

lude

PA

D, a

s it

coul

d be

a

fals

e el

evat

ion.

Figu

re 2

. Foo

t ass

essm

ent i

n pe

ople

with

dia

bete

s(F

or fe

atur

es o

f act

ive

diab

etic

foot

con

ditio

ns, s

ee F

igur

e 1)

Clinical findings Risk-based management

Foo

t ex

amin

atio

n a

nd

tes

ts†

Pati

ent

edu

cati

on

Non

e

OR

Sim

ple

callu

s

Ass

ess

at le

ast

once

a y

ear

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er t

o s

pec

ialis

t o

r p

od

iatr

y as

nee

ded

Thic

k ca

llus

requ

iring

tre

atm

ent

OR

Def

orm

ity

with

sim

ple

callu

s or

thi

ck

callu

s re

quiri

ng t

reat

men

t

OR

One

of:

• D

efor

mity

•

PAD

•

Neu

ropa

thy

Ass

ess

at le

ast

ever

y si

x m

onth

s

LOW

RIS

KM

OD

ER

AT

E R

ISK

HIG

H R

ISK

Pre

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s fo

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or

ampu

tatio

n

OR

CK

D s

tage

5 (e

GFR

<15

ml/m

in/1

.73m

2 )

OR

Cal

lus

with

intr

ader

mal

ble

edin

g

OR

Two

or m

ore

of:

• D

efor

mity

or

any

callu

s•

PAD

• N

euro

path

y Ass

ess

at le

ast

ever

y th

ree

to f

our

mon

ths

Cal

lus,

in

clud

ing:

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mpl

e ca

llus

• Th

ick

callu

s re

quiri

ng

trea

tmen

t

• C

allu

s w

ith

intr

ader

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eedi

ng

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orm

ity

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or

func

tiona

l im

pairm

ent

beca

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defo

rmity

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Neu

rop

athy

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ere

or

wor

seni

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sym

ptom

s,

such

as

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bnes

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pain

, or

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ing

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atio

n,

with

out

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estiv

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D

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the

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win

g:

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est

pain

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scul

ar

clau

dica

tion

• S

ever

e or

w

orse

ning

sy

mpt

oms

of

neur

opat

hy,

with

find

ings

su

gges

tive

of P

AD

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ers

Furt

her

ref

erra

l co

nsi

der

atio

ns

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rcot

art

hrop

athy

as

sug

gest

ed b

y cl

inic

al o

r X

-ray

fin

ding

s, s

uch

as

mid

foot

col

laps

e,

join

t des

truc

tion,

jo

int s

ublu

xatio

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or m

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ent

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ure

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gg

esti

ng

at

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al f

orm

s o

f d

iab

etic

n

euro

pat

hy o

r ca

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euro

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ther

th

an

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bet

es, s

uch

as

acu

te

on

set,

asy

mm

etri

cal

dist

ribu

tion,

or

mot

or d

efici

ts

wor

se th

an s

enso

ry d

efici

ts12

Co

rn, c

allu

s,

def

orm

ity, o

r p

ath

olo

gic

al

toen

ail

nee

din

g

man

agem

ent

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er t

o

ort

ho

pae

dic

sR

efer

to

va

scu

lar

Ref

er t

o

neu

rolo

gy

Ref

er t

o

po

dia

try

Ref

erra

l as

nee

ded

Sym

pto

ms

• G

lyca

emic

co

ntro

l

• S

mok

ing

hist

ory

• Fo

ot c

are

• Fo

otw

ear

• S

kin

inte

grity

• To

enai

l

AB

PI, a

nkle

-bra

chia

l pre

ssur

e in

dex;

CK

D, c

hron

ic k

idne

y di

seas

e; D

FU, d

iabe

tic fo

ot u

lcer

s;

eGFR

, est

imat

ed g

lom

erul

ar fi

ltrat

ion

rate

; PA

D, p

erip

hera

l art

eria

l dis

ease

† D

iagn

osis

of P

AD

or n

euro

path

y (if

ava

ilabl

e) c

ould

als

o be

use

d fo

r DFU

risk

str

atifi

catio

n.

Exam

inat

ion

and

test

find

ings

of P

AD

and

neu

ropa

thy

show

n he

re a

re fo

r the

pur

pose

of

DFU

ris

k st

ratifi

catio

n, a

nd m

ay n

ot b

e di

agno

stic

of P

AD

or

neur

opat

hy.

Ris

k st

rati

fica

tio

n

Med

ical

H

isto

ry

See ‘Referral’ on page 2

Figu

re 3

. Foo

t exa

min

atio

n an

d te

sts

in ri

sk s

tratifi

catio

n fo

r dia

betic

foot

ulc

ers

Deformity

• In

spec

t bo

th f

eet

thor

ough

ly b

y ex

amin

ing

skin

inte

grit

y, e

spec

ially

are

as w

ith

callu

s or

def

orm

ity.

• Lo

ok f

or d

efor

mit

y th

at in

crea

ses

rubb

ing

in f

ootw

ear

or p

ress

ure.

Ham

mer

toe

Hal

lux

valg

usC

allu

s

Neuropathy

10 g

mon

ofila

men

t (p

refe

rred

tes

t)12

8 H

z tu

ning

for

k

Neu

roth

esio

met

er

PAD

• P

alpa

te p

edal

pu

lses

(dor

salis

ped

is a

nd p

oste

rior

tibia

l) on

eac

h fo

ot.

• If

any

ped

al p

ulse

is a

bsen

t:

Obt

ain

ankl

e-b

rach

ial p

ress

ure

ind

ex (

AB

PI)

of

eac

h fo

ot: m

easu

re s

ysto

lic a

nkle

pre

ssur

e of

eac

h fo

ot; m

easu

re s

ysto

lic b

rach

ial p

ress

ure

of e

ach

arm

; div

ide

each

ank

le p

ress

ure

by t

he

grea

ter

of t

he t

wo

brac

hial

pre

ssur

es.

O

btai

n ab

solu

te

syst

olic

to

e p

ress

ure

of

eac

h bi

g to

e.

OR

Post

erio

r tib

ial

Toe

pres

sure

AB

PI

Dor

salis

ped

is

• A

sk p

atie

nt t

o cl

ose

both

eye

s.

• A

pply

pre

ssur

e w

ith a

10

g m

on

ofi

lam

ent

on b

ack

of p

atie

nt’s

han

d un

til it

bu

ckle

s. T

his

will

be

the

base

line

sens

atio

n fo

r su

bseq

uent

com

paris

on.

•Assessplantarregionoffirst,third,andfifthmetatarsalheads,andthebigtoe

of e

ach

foot

— a

tot

al o

f ei

ght

site

s fo

r bo

th f

eet.

Ask

pat

ient

to

info

rm e

xam

iner

w

hene

ver

pres

sure

is f

elt.

• P

lace

the

neu

roth

esio

met

er p

robe

at

the

dist

al t

ip o

f ea

ch b

ig t

oe.

• B

egin

at

0 V,

incr

easi

ng v

olta

ge g

radu

ally

unt

il pa

tient

feel

s vi

brat

ion.

• Ta

ke t

hree

mea

sure

men

ts a

nd a

vera

ge t

he r

eadi

ngs.

• A

sk p

atie

nt t

o cl

ose

both

eye

s.

• P

lace

an

activ

ated

128

Hz

tun

ing

fork

ove

r th

e in

terp

hala

ngea

l joi

nt o

f ea

ch b

ig t

oe.

• A

sk p

atie

nt t

o in

form

exa

min

er w

hen

vibr

atio

n is

no

long

er f

elt.

OR

OR

PAD

, per

iph

eral

art

eria

l dis

ease

4

5

Figure 4. Patient education aid on foot care and footwear(This aid is designed to complement, and not replace, education or advice provided by a healthcare professional)

Foot care

• Clean feet daily with mild soap and water

• Dry thoroughly between each toe

• Use a pumice stone or foot file to gently remove hard skin

• Avoid cutting nails too short; cut them straight across and file corners

Maintain good foot care and hygiene

• Avoid using harsh soap

• Apply moisturiser daily but not between each toe

• Avoid scratching skin as it may lead to wound or bleeding

Moisturise regularly

• Clean small wound with saline before applying antiseptic and covering with a plaster

• Seek medical help if there is no improvement after two days or if there are signs of infection

Apply simple first aid for small wound

• Wear well-fitting covered shoes with socks

• Home sandals are recommended

• Check and remove any stones or sharp objects inside shoes before wearing them

Wear well-fitting and covered footwear

If signs of infection are present, such as redness, swelling, increased pain, pus, fever, or the wound starts to smell, seek medical help as soon as possible

Seek medical help if wound is not healing well, or worsens

Footwear

For better comfort

Soft cushioning inner sole

To support middle part of the foot (arch)

Firm at back and middle sections of the sole

Low heel

Firm back (heel counter)

To allow natural movement of toes when walking

Flexible at front section of the sole

To hold feet in place and reduce rubbing within shoes

Adjustable ankle fastening (lace or velcro)

• To let toes wiggle freely

• Make sure shoes are broad enough for feet and any deformities

• Make sure there is one thumb’s width of space between toes and tip of the shoes

Deep and wide toe box

To prevent too much moisture within shoes

Soft and breathable materials

Watch out for:

• Blister, wound, corn, callus, or toenail abnormality

• Redness, swelling, bruise, or increased warmth

Monitor feet every day

1. Ministry of Health, Singapore. Lower extremity amputation, including toe amputation, in people with diabetes. 2016. Unpublished.

2. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care. 1990;13(5):513-521.

3. Vileikyte L. Diabetic foot ulcers: a quality of life issue. Diabetes Metab Res Rev. 2001;17(4):246-249.

4. Bus SA, Lavery LA, Monteiro-Soares M, et al.; International Working Group on the Diabetic Foot. IWGDF guideline on the prevention of foot ulcers in persons with diabetes. 2019. Available from: https://iwgdfguidelines.org/wp-content/uploads/2019/05/02-IWGDF-prevention-guideline-2019.pdf [Accessed 27 May 2019].

5. National Institute for Health and Care Excellence (NICE). Diabetic foot problems: prevention and management. 2016. NICE clinical guideline 19.

6. American Diabetes Association. 11. Microvascular complications and foot care: standards of medical care in diabetes 2019. Diabetes Care. 2019;41(Suppl 1):S124-S138.

7. Embil JM, Albalawi Z, Bowering K, et al.; Diabetes Canada Clinical Practice Guidelines Expert Committee. Foot care. Can J Diabetes. 2018;42(Suppl 1):S222-S227.

8. Scottish Intercollegiate Guidelines Network (SIGN). Management of diabetes. 2017. SIGN publication no. 116.

9. Hingorani A, LaMuraglia GM, Henke P, et al. The management of diabetic foot: a clinical practice guideline by the Society of Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg. 2016;63(Suppl 2):3S-21S.

10. Liu M, Zhang W, Yan Z, et al. Smoking increases the risk of diabetic foot amputation: A meta-analysis. Exp Ther Med. 2018;15(2):1680-1685.

11. Andersen CA. Noninvasive assessment of lower-extremity hemodynamics in individuals with diabetes mellitus. J Vasc Surg. 2010;52(Suppl 3):76S-80S.

12. Pop-Busui R, Boulton AJ, Feldman EL, et al. Diabetic neuropathy: a position statement by American Diabetes Association. Diabetes Care. 2017;40(1):136-154.

Expert Group

Chairpersons

Dr Elaine Tan (NHGP)

Dr Julian Wong (NUHCS)

Group members

Dr David Carmody (SGH)

Dr Sadhana Chandrasekar (TTSH)

Dr Chan Yee Cheun (NUH)

Dr Cheah Ming Hann (NUP)

Ms Chioh Mei Suang (AIC)

Ms Foo Mei Ching (SHP)

Ms Chelsea Law Chiew Chie (KTPH)

A/Prof Inderjeet Singh Rikhraj (SGH)

Dr Donna Tan Mui Ling (NHGP)

Mr Tan Liang Sheng (NUP)

Dr Derek Tse Wan Lung (SHP)

Dr Theresa Yap

(Yang & Yap Clinic & Surgery)

Ms Yeo Loo See (NHGP)

References

About the Agency

The Agency for Care Effectiveness (ACE) is the national health technology assessment agency in Singapore residing within the Ministry of Health (MOH). ACE develops evidence-based “Appropriate Care Guides” or ACGs to guide a specific area of clinical practice. ACGs are aimed at complementing MOH Clinical Practice Guidelines when these are available, by providing additions and updates as reflected in the evidence at the time of development, and incorporating cost-effectiveness considerations where relevant. The ACGs are not exhaustive of the subject matter. When using the ACGs, the responsibility for making decisions appropriate to the circumstances of the individual patient remains with the healthcare professional. This ACG will be reviewed 3 years after publication, or earlier, if new evidence emerges that requires substantive changes to the recommendations.

Find out more about ACE at www.ace-hta.gov.sg/about

© Agency for Care Effectiveness, Ministry of Health, Republic of SingaporeAll rights reserved. Reproduction of this publication in whole or in part in any material form is prohibited without the prior written permission of the copyright holder. Application to reproduce any part of this publication should be addressed to:

Agency for Care EffectivenessEmail: ACE_HTA@moh.gov.sg

In citation, please credit the “Ministry of Health, Singapore”,when you extract and use the information or data from the publication.

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