A refresher on diabetic foot care

Diabetes-related foot ulcers “usually develop in a person with diabetes simultaneously having one or more risk factors such as diabetes-related peripheral neuropathy and/or peripheral artery disease (PAD) in combination with a precipitating event,” according to the International Working Group on the Diabetic Foot. 

A precipitating event could be something as seemingly benign as a callus. 

“When I see a callus, I understand that’s a pre-ulcerative lesion that could go south and become an ulcer or lead to infection, osteomyelitis, and amputation,” Dr. Robyn Evans, medical director of the Wound Healing Clinic at Women’s College Hospital, lecturer at the University of Toronto, member of the Board of Directors of Wounds Canada, and full-time community family physician, said.

“But I think there’s a lot of people in the community—physicians—who aren’t necessarily aware of how quickly a pre-ulcerative lesion can develop and evolve.”

This is where more education on diabetic foot care is needed for physicians and patients. 

A part of preventive foot care is annual diabetic foot screening. However, a 2022 scoping review showed only 53% of Canadians with diabetes reported receiving an annual foot exam by a healthcare professional. 

There are many contributing factors for this. Patients may not have access to a family physician or are seen by different specialists for their diabetes, but not necessarily for foot care, which in Ontario is not covered under the Ontario Health Insurance Plan (OHIP), Dr. Evans said. 

Also, no requirement exists for what a national foot screen would look like, she said.

Virginie Blanchette, professor in Podiatric Medicine at Université du Québec à Trois-Rivières, and co-investigator, Diabetes Action Canada, Diabetic Foot Care and Amputation Prevention Research Group, recommends Inlow’s 60-second Diabetic Foot Screen. This Wounds Canada tool is grounded in international best practices, and already available in English and French, Blanchette wrote in an email.

Blanchette emphasizes that screening does not equal prevention. “Identifying a high-risk individual without a clear management pathway is incomplete,” she wrote. 

From an Indigenous perspective, but applicable to all diabetic patients, she added that “the tool should trigger a cascade of culturally safe interventions, education, footwear support, access to specialists, involvement of the patient in decision-making, and this is where the interprofessional team needs to operate with primary, specialized care.”

However, a challenge for physicians is knowing what the pathway is to multidisciplinary care. Offloading is a key component of preventive care, which requires the expertise of a podiatrist or chiropodist. 

In the case of a developing callus, a physician in the community may not know that the patient should be in some sort of offloading device.

“In terms of what physicians know about the types of footwear and offloading, I think it’s limited and they need somewhere to send them (patients),” Dr. Evans said. “I think the missing piece is that we don’t cover foot screening through chiropodists, who understand how to offload.”

Another challenge for physicians is getting patients seen quickly by a multidisciplinary team for any kind of injury on the foot or open wound. This leaves physicians in the community managing the wound in the meantime or sending the patient to the emergency department, if they’re worried, Dr. Evans said.

“Debridement of nonviable tissue and general principles of wound care include the provisions of a physiologically moist wound environment, and off-loading the ulcer,” is recommended in the Diabetes Canada Clinical Practice Guidelines.

However, moist dressings should not be used for ischemic ulcers.

A key message about dressings in Diabetes Canada Clinical Practice Guidelines is that, “proprietary adjunctive wound dressings and technologies, including antimicrobial dressings, lack sufficient evidence to support routine use in the treatment of neuropathic ulcers.”

Furthermore, it is recommended that specimens for culture are taken from deeper tissues by debridement, rather than the surface of the wound, as they are more likely to determine the correct bacterial pathogens for antimicrobial therapy.

A helpful article for physicians in the prevention and management of diabetic foot ulcers is A Foot Health Pathway for People Living with Diabetes: Integrating a Population Health Approach. It provides physicians with the different levels of risk for ulcers and amputations and the actions to take. It also gives information to help physicians build an individualized plan of care in partnership with patients.

“Importantly, wound care does not begin with the wound. It begins with addressing the determinants of wellness that enable prevention,” Blanchette wrote. 

This is particularly important in Indigenous populations. 

“Historical trauma, discrimination in healthcare, and previous experiences of racism directly affect whether Indigenous patients seek care and engage in prevention,” Blanchette wrote.

Blanchette recommends that physicians listen for barriers, cultural preferences, and priorities before examining a patient’s feet. This gives the patient autonomy, builds trust, and gives the physician critical context for what prevention strategies will be feasible, while showing the patient respect, she wrote. 

Shared decision-making necessitates that both physicians and patients have access to educational resources on preventive strategies. With consistent application of these strategies and timely collaboration with multidisciplinary teams, including podiatrists or chiropodists, many diabetic foot ulcers and lower limb amputations—devastating but often preventable outcomes—can be avoided.

Excellent resources for physicians and patients can be found on the Diabetes Canada and Wounds Canada websites.