Preventing Foot Ulcers in People With Diabetes

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Singh N, Armstrong DG, Lipsky BA: Preventing foot ulcers in patients with diabetes. JAMA 293:217-228, 2005.

What is the problem and what is known about it so far?

As many as one in four people with diabetes will develop a foot ulcer (sore) in their lifetime. Foot ulcers can become infected, cause disability, and ultimately lead to limb amputation (removal).

Who was studied?

People with diabetes.

How was the study done?

Researchers searched online for recent medical articles on diabetic foot ulcers. They found 165 articles published between 1980 and 2000.

What did the researchers find?

The leading cause of foot ulcers is peripheral neuropathy (nerve damage). Pressure on the sole of the foot is another cause. Repeated rubbing against the foot can lead to ulcers, as can injuries (caused by things like cutting toenails), especially from falls. People with diabetes may have problems with wound healing, so ulcers don’t get better.

Doctors taking care of patients with diabetes should be aware of their risk factors. These include previous foot ulcers, previous amputation, having diabetes for a long time, trouble controlling blood glucose, and vision problems. Feet should be examined for problems such as calluses, hammertoes, and bunions. Doctors should check joints for flexibility. They should look for dry skin, fissures (cracks), and other skin problems. They also should check that patients' shoes fit well.

Loss of feeling in the feet can keep people from realizing they're getting an ulcer. Several tests are used to check for loss of feeling. The most common is the monofilament test. The tester gently touches parts of the foot with a thin plastic thread to find areas of reduced feeling. Other devices, such as tuning forks, use vibration to test for feeling.

Helping patients understand the causes and treatments lowered the risk of foot ulcers and limb amputations.

A 1-day workshop on foot care for doctors and nurses helped patients better care for themselves. Published guidelines for doctors recommend that every patient have a yearly foot examination.

Tighter blood glucose control leads to a lower risk of peripheral neuropathy. Stopping smoking may also help. Some studies found that people who smoke are at higher risk for foot ulcers and amputation. Referrals to podiatrists (foot specialists) can get patients needed treatment. Specially made shoes may possibly help.

Patients under the care of podiatrists had fewer deep ulcers. Patients under the care of multidisciplinary teams (a group of health care providers that may include podiatrists and other specialists, nurses, dietitians, and social workers) were at lower risk for amputation.

What were the limitations of this study?

Some studies found custom footwear helped prevent ulcers, but others did not. More studies are needed to find the best ways to educate patients.

What are the implications of the study?

All patients with diabetes should be screened for foot ulcer risk.