Document type
Patient information
Place
East and North Hertfordshire
Output type
Clinical Pathways
Pathway
Foot Health for Diabetic Patients pathwayUrgent Diabetic Foot - Charcot pathway

Foot Health for Diabetic Patients

When examining the feet of a person with diabetes, remove their shoes, socks, bandages and dressings, and examine both feet for evidence of the following risk factors:· Neuropathy (use a 10g monofilament as part of a foot sensory examination; Limb ischaemia (see what NICE says on lower limb peripheral arterial disease); Ulceration; Callus; Infection and/or inflammation; Deformity; Gangrene; Charcot arthropathy.  Use ankle brachial pressure index in line with NICE’s recommendations on lower limb peripheral arterial disease. Interpret results carefully in people with diabetes because calcified arteries may falsely elevate results (see pathway)

RED FLAGS - urgent/ emergency: Any one of the following: New ulcer identified or Swelling or Discoloration or Infection or Acute pain in lower leg in the absence of trauma or Any suggestion that this could this be Charcot (Suspect acute Charcot arthropathy if there is redness, warmth, swelling or deformity especially in the presence of peripheral neuropathy or chronic kidney disease. Consider acute Charcot arthropathy even when deformity is not present or pain is not reported).  See Urgent Diabetic Foot/ Charcot pathway - if suspicion of charcot or systemically unwell - emergency referral to AAU.  Start antibiotics if sign of infection.  NB: patient should be seen by MDDT foot team within 24hrs

Categorise as low, moderate or high risk

  • Low risk = no risk factors except callus alone
  • Moderate risk = one of any of the following:
    • Deformity or Neuropathy or Non-critical limb ischaemia (asymptomatic with lack of normal pulses or stable claudication without rest pain) or CKD stage 3 (eGFR <60)
  • High risk:
    • Previous ulceration or 
    • Previous amputation or 
    • On renal replacement therapy or 
    • Neuropathy and non-critical limb ischaemia together or 
    • Neuropathy in conbination with callus and/or deformity or
    • Non-critical limb ischaemia in combination with callus and/or deformity

Manage according to risk

  • Low risk - give low risk card and review in one year
  • Moderate risk - give moderate risk card and refer to podiatry service.  Fully complete referral form including level of risk.  Results should be documented and shared and patient reviewed in 3-6 months
  • High risk - give high risk card and refer to podiatry service.  Fully complete referral form including level of risk.  Results should be documented and shared and patient reviewed in 1-3 months
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