Chapter 35

Diabetic foot: primary prevention and

Key message
Shoes are not primarily suitable for offloading in the case of ulcers. Only when a non-
removable knee-high device is contraindicated or not tolerated by the patient it should
be considered, and then only when it is acceptable to the patient. The loss of the gift of
pain is a very serious impairment and has to be addressed with proper footwear. The
examination primarily screens for loss of protective sensation (LOPS) and peripheral
artery disease (PAD) to prioritize treatment and guide follow-up scheduling. All patients
with diabetes need special attention for their footwear and special education on footcare
and shoe adherence. All patients in risk category one or more need regular professional
control. The general footwear advises for diabetics are of utmost importance for all foot
professionals and diabetics. Proper size and volume (no pressure spots possible), no
stitches inside, foot orthosis with pressure distributing properties, proper balanced out
the pros and cons of a rocker profile, optimal shoelock with closure.

Etiology and epidemiology of foot than for most cancers. Unfortunately, many of
complications these amputations could be avoided with prop-
The annual incidence of foot ulcers for people er screening, timely care, and proper prevention.
with diabetes is approximately 2%, conservative- Diabetes has multiple presentations, including
ly yielding a 25 - 34% lifetime risk for developing type 1 and type 2 diabetes. Type 1 diabetes occurs
a diabetes related ulceration.1, 2, 3 Approximately due to the inability of the human body to produce
50% of wounds will become infected, and be- insulin. Type 2 diabetes results from the body’s
tween 20 and 30% of these cases lead to some developed resistance to insulin. Obesity and met-
form of amputation. Therefore, it should come as abolic complications resulting from chronically
no surprise, that every twenty seconds, a limb is increased blood sugars may also play a role in the
amputated worldwide due to diabetic complica- harmful effects. Sensorimotor neuropathies and
tions.4 Following any diabetes-related amputa- peripheral vasculopathies can increase risk for
tion, the five-year patient mortality rate is greater development of a host of complications, most no-

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tably gait alteration, instability, skin ulceration, limited joint mobility cause increased plantar
infection, amputation and premature mortality. pressures and play a major role in diabetic foot
Healthy people with intact sensation and propri- disease.6 Decreasing foot pressures has repeated-
oception can sense each interaction of the low- ly been proven to reduce ulcer formation, thus,
er extremity during the stance phase. However, proper management and offloading through
diabetic patients with neuropathy and loss of methods such as orthopedic footwear may help
proprioception are unable to experience these prevent against the development of further dia-
sensations, increasing their risk of injury and betes related foot complications.6
falls. This loss of the gift of pain causes patients
to overexpose their feet to excessive plantar pres- The comprehensive diabetic foot
sures and shear stresses; greatly increasing their ­examination (CDFE)
risk of soft tissue breakdown, and likely delaying The assessment of lower extremity risk begins
their response time to seeking medical care. The with a complete patient history. Essential ele-
most common triad of causative factors for foot ments include the patient’s history of cigarette
ulceration is neuropathy, deformity, and trau- smoking, ulceration, gangrene or necrosis, Char-
ma.2,5 Gait abnormalities, biomechanical and cot neuroarthropathy, or lower extremity surgery
osseous deformities, soft tissue changes, and such as vascular stenting or amputation. His-

Figure 35.1
Core components
of the diabetic foot
examination.

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128 Hz tuning forks assess vibration perception to very low, low, moderate and high ulceration
quickly and easily over the tip of the great toe risk, respectively. In any of the diabetic patients,
bilaterally. An abnormal test requires the patient if mobility seems limited, physiotherapy may be
not detect the vibration while the tester still per- integrated as an adjunct to other therapies.9 All
ceives the vibration while holding the tuning patients should be educated on proper shoe se-
fork (Figure 35.3). lection and foot care.

The pinprick examination assesses pain per- Integration of foot orthoses and footwear
ception. The clinician applies a disposable pin modification based on ADA risk Category
just proximal to the toenail on the dorsal sur- With knowledge of the techniques listed above,
face of the hallux. Inability of the patient to one now has the tools to integrate therapy in a
detect pain represents an abnormal test result. more precise manner based on a given patient’s
The posterior tibial and dorsalis pedis foot pulses risk status.2, 5, 10
are palpated and characterized as either present
or absent. Diabetic patients with claudication, ADA risk category 0: Intact sensation,
rest pain, or non-healing ulcers also should be no ­history of ulcer
referred to a vascular specialist. This patient is at the lowest tier of risk and may
benefit from a simple, annual inspection by a foot
Classifying risk for ulceration or reulcera- specialist. Each visit should include basic risk
tion: The American Diabetes Association screening and advice on well-fitting athletic and
(ADA) risk classification (Table 35.1) comfort shoes for daily activity. Because these
Following the thorough examination as de- patients do not have signs of reduced protective
scribed above, the patient’s lower extremity risk sensation or peripheral arterial disease, their
status is graded on a scale of 0-3 corresponding risk for developing a wound is very low. These

Figure 35.2
Left: 10 Gram filament. b: test
positions. Right: test positions.

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 Table 35.1
ADA’s risk classification. LOPS: Loss of peripheral
patients will often do well in regular athletic or sensation. PAD: Peripheral artery disease.
walking shoes, and those with substantial pes
cavus (high arch) or pes planus (flat feet depres-
sion) may benefit from over the counter orthoses ADA risk category 1: Loss of protective sensa-
for palliative discomfort relief. In cases of com- tion, with or without deformity
plaints because of foot deformities, these deform- This patient, by virtue of their LOPS, is now at
ities should be treated as indicated. It is essential significantly greater risk for ulceration. Proper
to have an optimal fitting (length and width) and footwear is critical for this patient and should
ample space for hammer and/or clawing toes and be based specifically on location and level of de-
other deformities for preventing pressure spots, formity. At the very least, the majority of these pa-
an optimal closure on the instep for preventing tients require some type of custom foot orthosis
slipping and shear forces, and proper pressure to reduce peak plantar pressures and a more ac-
distribution on the sole. commodative athletic or comfort shoe to reduce
skin irritation.11,12 In fact, fitting patients with
diabetes and neuropathy is critically important,
as some 9 in 10 patients at risk of ulceration are
wearing poorly fitting shoes.12 People with greater
degrees of deformity, such as prominent osseous
structures or descended metatarsal heads, may
also require a prescriptive shoe. While rare in
Figure 35.3 category 1, severe deformities will require custom
128Hz Tuning fork. moulded shoes and possibly outsole modifica-

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 Figure 35.6
Examples of removable
high-knee walkers for
unloading. Upper: ready
made orthoses. Lower:
custom made orthosis.

tar pressure relieving effect during walking with diabetes. The specific modality depends
(i.e. 30% relief compared to plantar pressure on the type and location of the foot ulcer.
in standard of care therapeutic footwear), and
encourage the patient to wear this footwear. Surgical offloading interventions
7. Do not prescribe, and instruct the patient 9. Consider Achilles tendon lengthening, joint
with diabetes not to use, conventional or arthroplasty, single or pan-metatarsal head
standard therapeutic shoes to heal a plantar resection or osteotomy to prevent a recurrent
foot ulcer. foot ulcer when conservative treatment fails
8. Consider using shoe modifications, temporary in a high-risk patient with diabetes and a
footwear, toe spacers or orthoses to offload plantar foot ulcer.
and heal a non-plantar foot ulcer without is- 10. Consider digital flexor tenotomy to prevent a
chemia or uncontrolled infection in a patient toe ulcer when conservative treatment fails

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 in. The higher the heel elevation, the higher
the pressure at the metatarsal region, in nor-
mal shaped feet.
7. A removable insole makes inspection and ad-
aptations possible.
8.  For optimal pressure distribution at least
regular check with a Harrismat (qualitative
information), preferrably with inshoe foot
pressure measurements (quantitative infor-
mation), is necessary.
9. All patients should be educated on how don-
ning and doffing shoes. Mostly people forget
to push the heel to the counter and then lace
the shoes. When the foot, during donning, is
placed a little bit more forward in the shoe, Figure 35.9
lacing will not result in firm closing and the Left: outline of the foot. Middle: outline of the
foot will slip in and out the heel. removable insole and Right: the foot is clearly
10. In case of doubts if a ready-made shoe or a wider than the removable insole.
therapeutic shoe will cause high pressure
spots, provide the patient with a custom
made shoe.
11. In case of LOPS, diabetic socks without
seams should be advised.
12. Treatment with shoe adaptations / cus-
tom-made footwear is regular professional
inspection.
13. See also Chapter 19 Tips and tricks in pedor-
thic consultancy after 40 years of experience.

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