30150 • Diabetic Foot Ulcer Prevention and Care

Table of Contents

30150 • Diabetic Foot Ulcer Prevention and Care

How to Receive Credit

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Nursing Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. AN OVERVIEW OF DIABETES

EPIDEMIOLOGY

DIAGNOSIS

INTERVENTIONS THAT DECREASE THE RISK OF DEVELOPING DIABETES

3. RISK FACTORS FOR DEVELOPING DIABETIC FOOT ULCERS

NEUROPATHY

PERIPHERAL VASCULAR DISEASE

CHARCOT FOOT

4. GENERAL APPROACHES TO DIABETIC FOOT CARE

MULTIDISCIPLINARY DIABETIC FOOT TEAM

HOLISTIC APPROACH TO DIABETIC FOOT CARE

THE FOOT ASSESSMENT

EDUCATION RELATED TO DIABETIC FOOT CARE

5. DIABETIC FOOT ULCERS

ASSESSING A DIABETIC FOOT ULCER

CLASSIFICATION

HEALING DIABETIC FOOT ULCERS

DEBRIDEMENT AND WOUND BED PREPARATION

INFECTION AND THE DIABETIC FOOT ULCER

CHOOSING SUITABLE DRESSING AND TOPICAL TREATMENT

ADJUNCTIVE TREATMENT OPTIONS

ACHIEVING FINAL WOUND CLOSURE

RE-OCCURRENCE OF DIABETIC FOOT ULCERS

AMPUTATION

6. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

30150 • Diabetic Foot Ulcer Prevention and Care

Maryam Mamou, BSN, RN, CRRN, CWOCN

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

Diabetic foot ulcers are among the most serious and costly complications of diabetes and are a leading cause of infection, hospitalization, lower-extremity amputation, and diminished quality of life. This continuing education activity provides nurses with a comprehensive review of the pathophysiology, risk factors, prevention, assessment, and management of diabetic foot ulcers. The course examines the roles of peripheral neuropathy, peripheral arterial disease, Charcot neuroarthropathy, foot deformities, and other contributing factors that increase the risk of ulcer development. Participants will learn how to perform focused diabetic foot assessments, recognize early signs of complications, and implement evidence-based prevention strategies, including patient education, footwear selection, and routine foot surveillance. The activity also reviews current approaches to ulcer management, including offloading, wound assessment, debridement, infection management, advanced wound therapies, and recurrence prevention. Emphasis is placed on interdisciplinary collaboration and the nurse's critical role in identifying at-risk patients, promoting self-care, supporting wound healing, and reducing the incidence of ulcer-related complications and amputations.

30150 • Diabetic Foot Ulcer Prevention and Care

Education Category. Medical / Surgical

Release Date. 09/01/2026

Expiration Date. 08/31/2029

How to Receive Credit

To complete this course for continuing education credit please go to http://www.netce.com/course/3638 in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

Course Overview

Diabetic foot ulcers are among the most serious and costly complications of diabetes and are a leading cause of infection, hospitalization, lower-extremity amputation, and diminished quality of life. This continuing education activity provides nurses with a comprehensive review of the pathophysiology, risk factors, prevention, assessment, and management of diabetic foot ulcers. The course examines the roles of peripheral neuropathy, peripheral arterial disease, Charcot neuroarthropathy, foot deformities, and other contributing factors that increase the risk of ulcer development. Participants will learn how to perform focused diabetic foot assessments, recognize early signs of complications, and implement evidence-based prevention strategies, including patient education, footwear selection, and routine foot surveillance. The activity also reviews current approaches to ulcer management, including offloading, wound assessment, debridement, infection management, advanced wound therapies, and recurrence prevention. Emphasis is placed on interdisciplinary collaboration and the nurse's critical role in identifying at-risk patients, promoting self-care, supporting wound healing, and reducing the incidence of ulcer-related complications and amputations.

Audience

This course is designed for nurses in all practice settings caring for patients with diabetes at risk for or experiencing foot ulcers.

Accreditations & Approvals

In support of improving patient care, TRC Healthcare/NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Designations of Credit

NetCE designates this continuing education activity for 5 ANCC contact hour(s). NetCE designates this continuing education activity for 6 hours for Alabama nurses. NetCE is authorized by IACET to offer 0.5 CEU(s) for this program. AACN Synergy CERP Category A.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353 (valid through July 30, 2029); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2027; South Carolina, Provider #50-2405; West Virginia RN and APRN, Provider #50-2405.

Course Objective

The purpose of this course is to improve nurses' knowledge, skills, and clinical practice related to the assessment, prevention, and management of diabetic foot ulcers and the prevention of ulcer recurrence.

Learning Objectives

Upon completion of this course, you should be able to:

1. Describe how diabetes, peripheral neuropathy, peripheral arterial disease, foot deformity, Charcot neuroarthropathy, and other risk factors contribute to the development of diabetic foot ulcers.

2. Perform a focused diabetic foot assessment that includes skin integrity, protective sensation, vascular status, foot structure and deformity, footwear, and other factors that influence ulcer risk.

3. Discuss key aspects of patient education related to diabetic foot care.

4. Identify evidence-based strategies for preventing and managing diabetic foot ulcers.

5. Develop strategies to promote healing of diabetic foot ulcers and related infections.

6. Evaluation approaches to preventing recurrence of diabetic foot ulcers.

Faculty

Maryam Mamou, BSN, RN, CRRN, CWOCN, is an Irish-trained RN who has lived and worked in the United States for 20 years. During her career, she has completed a BSN and went on to become a certified rehabilitation nurse, a certified life care planner, and more recently a certified wound ostomy and continence nurse. She is a graduate of the wound ostomy and continence program at Emory University in Atlanta, Georgia, and is nationally certified in these areas.

Ms. Mamou has worked in various rehabilitation settings and has first-hand experience of how pressure ulcers impact patients' recovery and quality of life. She has held positions as staff nurse, unit coordinator, educator, and director of nursing in home health care. She has been involved in developing and implementing several staff education programs in a variety of settings. She was most recently employed as a wound ostomy and continence nurse at East Alabama Medical Center in Opelika, Alabama.

Faculty Disclosure

Contributing faculty, Maryam Mamou, BSN, RN, CRRN, CWOCN, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Mary Franks, MSN, APRN, FNP-C

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Diabetic foot complications are a major source of morbidity and disability among people with diabetes. Peripheral neuropathy, peripheral arterial disease, foot deformities, and other diabetes-related complications can increase the risk of skin breakdown and impair the body's ability to heal once an ulcer develops. Diabetic foot ulcers may become infected, progress to deeper tissue involvement or osteomyelitis, and in severe cases contribute to lower-extremity amputation. Importantly, many diabetic foot ulcers are preventable through early identification of risk factors, appropriate foot surveillance, patient education, pressure reduction and offloading, and timely management of wounds and infections.

2. AN OVERVIEW OF DIABETES

EPIDEMIOLOGY

Diabetes is a progressive disease process influencing fuel metabolism by the body [1]. Carbohydrate, protein, and fat metabolism are altered when insulin, the mediator of fuel, is not available. Insulin deficiency can result from defects in insulin secretion and/or diminished tissue response to insulin. The result of this defect in insulin secretion and/or insulin resistance is hyperglycemia [2]. The chronic metabolic dysregulation associated with diabetes can result in long-standing damage to various organs, including the eyes, kidneys, nerves, heart, and blood vessels [1].

According to the Centers for Disease Control and Prevention (CDC), the prevalence of diagnosed diabetes has increased from 0.93% of the U.S. population in 1958 to 8.9% in 2021 [3]. It is important to note that 8.7 million adults have diabetes but remain undiagnosed [3,4].

The scope of the diabetes problem is vast and diverse. From 1994 through 2015, the prevalence of diagnosed diabetes increased across all states in the United States. In 1994, only one state had a prevalence greater than 6.0%. By 2018, all states had a prevalence greater than 6.0% and 35 states and Puerto Rico and Guam had rates exceeding 9.0% [5]. According to data from the Behavioral Risk Factor Surveillance System, Guam, West Virginia and Puerto Rico have the highest rates of adults with diabetes (15.4%, 13.4%, and 13.1%, respectively). Eight of the 10 states with the highest rates (12% to 12.9%) are in the South. Colorado ranked lowest with 6.6% [6]. Genetics, race, age, and lifestyle significantly influence the onset and progression of the disease process [2]. According to 2022 National Diabetes Statistics Report, the percentage of adults with diagnosed diabetes was highest among American Indians/Alaska Natives (14.5%), non-Hispanic Black Americans (12.1%), and people of Hispanic origin (11.8%), followed by non-Hispanic Asian Americans (9.5%) and non-Hispanic White Americans (7.4%) [3]. Native Americans/Alaska Natives present the greatest risk for the development of type 2 diabetes; their risk is more than two times greater than that of White Americans. Among Native American subgroups, the rate of diabetes among Alaska Natives is 6.0%, while Native Americans in Southern Arizona have rates of 22% [3].

DIAGNOSIS

The most common types of diabetes are type 1 and type 2. However, gestational diabetes is also relatively common and is a source of significant morbidity and mortality. Gestational diabetes complicates approximately 10% of all pregnancies [7,8]. It is first recognized in pregnancy, usually after 24 weeks of gestation, and typically resolves after the birth of the child [7]. Other less common types of diabetes include [9,10]:

- Maturity-onset diabetes of the young: A genetic, autosomal-dominant defect of the pancreatic beta cells, resulting in insulin deficiency and decreased insulin release without the presence of insulin resistance and obesity. This form of diabetes typically develops in patients younger than 25 years of age. It is a different clinical entity than type 2 diabetes of the adolescent, which presents with insulin resistance.

- Diabetes related to diseases of the exocrine pancreas, such as cystic fibrosis, and various endocrine diseases, such as Cushing syndrome, acromegaly, and chromocytoma

- Drug-induced diabetes resulting from the use of certain medications, particularly high-dose corticosteroids

American Diabetes Association (ADA) criteria for screening for diabetes or prediabetes in asymptomatic adults include [7,11]:

- Testing should be considered in adults with overweight or obesity (body mass index ≥25 kg/m^2 or ≥23 kg/m^2 in Asian Americans) who have one or more of the following risk factors:

- First-degree relative with diabetes

- High-risk race/ethnicity (e.g., African American, Hispanic American, Native American, Alaskan Native, Pacific Islander, Asian American)

- History of cardiovascular disease

- Hypertension (blood pressure ≥140/90 mm Hg or on therapy for hypertension)

- HDL cholesterol level <35 mg/dL and/or a triglyceride level >250 mg/dL

- Women with polycystic ovarian syndrome

- Physical inactivity

- Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)

- Patients with prediabetes (A1c ≥5.7%, impaired glucose tolerance, or impaired fasting glucose) should be tested yearly.

- Women who were diagnosed with gestational diabetes should have lifelong testing at least every three years.

- For all other patients, testing should begin at 35 years of age. If results are normal, testing should be repeated at a minimum of three-year intervals, with consideration of more frequent testing depending on initial results and risk status.

- People with human immunodeficiency virus (HIV)

The diagnostic criteria for type 2 diabetes are fairly straightforward and are based on fasting plasma glucose and postprandial plasma glucose levels (Table 1). After a diagnosis of type 2 diabetes has been definitively made, education on self-care management is necessary in order to obtain euglycemia and prevent complications related to the detrimental effects of hyperglycemia [7]. It is estimated that as many as 90% of patients with type 2 diabetes will require oral medications to achieve adequate glucose control within five years of diagnosis [7]. When glucose levels cannot be adequately controlled with oral medications, the use of injectable medications is necessary. If elevated blood glucose levels are untreated and continue to rise, the result can be hyperosmolar hyperglycemia syndrome (HHS) and ultimately death [12].

Table 1: DIAGNOSTIC CRITERIA FOR TYPE 2 DIABETES

Stage

Fasting Plasma Glucose Level

Two-Hour Postprandial Plasma Glucose Level

Glycated Hemoglobin Components

Prediabetes

>100–125 mg/dL

≥140–199 mg/dL

5.7% to 6.4%

Diabetesa

≥126 mg/dL

≥200 mg/dL

≥6.5%

aA random blood glucose level ≥200 mg/dL with symptoms of hyperglycemia is also indicative of diabetes.

Source: [7]

INTERVENTIONS THAT DECREASE THE RISK OF DEVELOPING DIABETES

Studies show that behavioral changes, including dietary modifications, regular physical activity, and weight loss, significantly decrease the risk of individuals with prediabetes advancing to type 2 diabetes [13]. Goals may include a 7% loss of body weight for those who are overweight and participation in a moderate-intensity physical activity (e.g., walking) for at least 150 minutes weekly [14]. These lifestyle changes can best be achieved by referring patient with prediabetes to an ongoing support program.

Pharmacologic interventions may also be appropriate for selected individuals at particularly high risk. The ADA recommends considering metformin for diabetes prevention in adults at high risk, particularly those who are younger than 60 years of age, have a BMI ≥35 kg/m², have higher fasting glucose or A1C levels, or have a history of gestational diabetes [7]. Metformin has the strongest evidence base among medications specifically studied for diabetes prevention. Long-term use may be associated with vitamin B12 deficiency, so periodic assessment of B12 levels should be considered, particularly in individuals with anemia or peripheral neuropathy.

3. RISK FACTORS FOR DEVELOPING DIABETIC FOOT ULCERS

Diabetic foot ulcers are a common and potentially serious complication of diabetes, arising from a combination of neurologic, vascular, and musculoskeletal abnormalities that impair the foot's ability to withstand and recover from repetitive stress or injury. Several factors substantially increase the risk of ulceration, particularly peripheral neuropathy, peripheral vascular disease, and Charcot foot. Less common factors include peripheral arterial disease, foot deformity, history of foot ulcerations, past amputation, poor vision, renal disease, and suboptimal glucose control [16]. Peripheral vascular disease can reduce tissue perfusion and impair wound healing, while Charcot foot causes progressive bone and joint destruction, deformity, and abnormal pressure distribution that can increase the risk of skin breakdown. Recognizing these risk factors is essential for identifying patients who require closer surveillance and implementing preventive interventions before an ulcer develops.

NEUROPATHY

Neuropathy is one of the most common causes of diabetic foot ulceration [16]. It can diminish protective sensation and alter foot biomechanics, allowing repetitive trauma or minor injuries to go unnoticed. Patients with diabetes and neuropathy have a sevenfold increase risk of developing foot wounds compared with people with diabetes who are free from neuropathy [16]. More than 60% of those diagnosed with diabetes will go on to develop neuropathy [17]. It is especially prevalent in those who have had diabetes for more than 10 years and have poorly controlled blood glucose levels [18].

It is still not clearly understood how diabetes causes neuropathy [19]. Currently, it is believed that glucose deregulation is the catalyst for metabolic and vascular abnormalities, causing nerve malfunction and eventual nerve loss [19]. Patients with diabetes should be educated regarding the signs and symptoms of diabetic neuropathy, allowing help-seeking in the early stages of the condition when treatment is more effective [19].

Forms of Diabetic Neuropathy

Diabetic neuropathy encompasses a group of nerve disorders caused by chronic hyperglycemia and other metabolic and vascular factors associated with diabetes. Although distal symmetric polyneuropathy (DSPN) is the most common form and is particularly important in the development of diabetic foot complications, diabetes can affect multiple types of nerves. The clinical presentation varies according to the nerves involved and may include sensory loss, pain, weakness, autonomic dysfunction, or focal neurologic deficits.

In more severe forms, neuropathy can cause weakness and stiffness, leading to problems with balance and ambulation [19]. Diabetic neuropathy will eventually result in a loss of protective sensation (LOPS), which leaves the foot vulnerable to injury and ulceration [16]. Unfortunately, mild neuropathy is missed in an estimated 60% of cases, and severe forms are not detected in about 30% of patients [19]. This underdiagnosis can result in the condition progressing unchecked, leading to irreversible nerve damage [19].

Focal and Multifocal Neuropathies

Diabetes can also cause focal or multifocal nerve disorders. Diabetic amyotrophy (diabetic lumbosacral radiculoplexus neuropathy) typically presents with acute or subacute pain and weakness involving the hip, thigh, or buttock and may be followed by muscle wasting. Entrapment neuropathies, such as carpal tunnel syndrome, are also more common in people with diabetes. Less commonly, diabetes may cause isolated cranial or peripheral nerve palsies. The usual pattern for multifocal or diffuse neuropathy is that it begins in the toes, progressing up the leg; it what has been described as a stocking pattern of sensory loss [21].

Motor Neuropathy

Motor neuropathy causes problems with ambulation, and over an extended period of time, patients with motor neuropathy can lose up to half of the muscle volume of their feet [18]. Common signs and symptoms include progressive muscle weakness, visible muscle atrophy, loss of deep tendon reflexes (e.g., Achilles reflex), poor balance, foot drop, and foot deformities (e.g., claw toes).

Autonomic Neuropathy

Diabetic autonomic neuropathy affects nerves that regulate involuntary functions, including cardiovascular, gastrointestinal, genitourinary, and sudomotor functions. In the feet, autonomic dysfunction can reduce sweating and lead to dry, cracked skin, which increases susceptibility to skin breakdown and infection. Autonomic neuropathy may therefore contribute indirectly to diabetic foot ulcer development, particularly when combined with sensory neuropathy [18].

Distal Symmetric Polyneuropathy (DSPN)

Distal symmetric polyneuropathy (DSPN) is the most common diabetic neuropathy and typically develops gradually in a length-dependent, symmetric pattern, initially affecting the toes and feet before progressing proximally. Patients may experience numbness, tingling, burning, or electric or shooting pain. However, some patients have predominantly sensory loss without pain and may be unaware of injuries to their feet [22,23].

As the neuropathy progresses, loss of protective sensation becomes particularly important in relation to diabetic foot ulcers. Patients may not perceive pressure, friction, thermal injury, or minor trauma, allowing repetitive injury to continue without recognition. Motor involvement can also contribute to muscle weakness and foot deformities, altering pressure distribution across the foot and further increasing ulcer risk [23].

Diagnosis

The diagnosis of diabetic neuropathy is primarily clinical, based on the patient's history, symptoms, and neurologic examination. Because diabetic neuropathy can present in different forms and may be asymptomatic, routine assessment is important, particularly for individuals at increased risk for diabetic foot complications. The evaluation should also consider other potential causes of neuropathy, because not all peripheral nerve dysfunction in a person with diabetes is attributable to diabetes.

The assessment begins with a detailed history of neurologic symptoms and their progression. Patients should be asked about numbness, tingling, burning, electric or shooting pain, sensitivity to touch, weakness, balance problems, and changes in gait. Particular attention should be given to symptoms involving the feet and lower extremities and whether they are symmetric and progressively extend from the toes proximally, a pattern characteristic of DSPN. A history of foot injuries, falls, burns, blisters, or wounds that the patient did not initially notice can provide an important indication of loss of protective sensation.

In addition, sensory, motor, and reflex function should be assessed. In patients with suspected DSPN, examination commonly includes assessment of [24]:

- Pressure sensation, particularly with 10-g monofilament

- Vibration perception, commonly using a 128-Hz tuning fork

- Pinprick or temperature sensation

- Ankle reflexes

- Muscle strength and tone

- Gait and balance

Loss of protective sensation is particularly important when evaluating the risk of diabetic foot ulceration. The 10-g monofilament test is commonly used to identify patients with clinically significant sensory loss. However, monofilament testing should generally be performed in combination with another assessment of sensory function, rather than being used as the sole diagnostic test [24].

Certain findings should prompt consideration of diagnoses other than typical diabetic DSPN. These include marked asymmetry, rapid progression, prominent motor weakness, acute onset, an unusual distribution of symptoms, or significant systemic features. In such cases, additional neurologic evaluation and diagnostic testing may be warranted.

Treating Neuropathy

Treatment of diabetic neuropathy focuses on preventing or slowing further nerve damage, managing symptoms, and addressing complications that may increase the risk of injury, particularly to the feet. Optimal glycemic management is an important component of treatment. Evidence from the Diabetes Control and Complications Trial (DCCT) demonstrated that intensive insulin therapy reduced the risk of developing diabetic neuropathy and slowed its progression in people with type 1 diabetes [21]. However, glycemic optimization does not reliably reverse established neuropathy, and treatment should therefore also address neuropathic symptoms and modifiable risk factors.

Correctly Fitting Shoes

It is estimated that up to 80% of diabetic foot ulcers are related to pressure from poorly fitting footwear [16]. As such, correctly fitting shoes are a mainstay in the prevention of foot injury for patients with diabetes and peripheral neuropathy [22]. Shoes should fit comfortably and should be correctly sized. Unwittingly, many individuals with peripheral neuropathy wear shoes that are too tight, because the reduced sensory function requires that footwear squeeze the feet before it is felt. Shoes should have an ample toe box that does not press down on the toes or squeeze them together from side to side [18].

Evidence Based Practice Recommendation

According to the American Diabetes Association, the use of specialized therapeutic footwear is recommended for people with diabetes at high risk for ulceration, including those with loss of protective sensation, foot deformities, ulcers, callous formation, poor peripheral circulation, or history of amputation.

https://diabetesjournals.org/care/article/49/Supplement_1/S261/163919/12-Retinopathy-Neuropathy-and-Foot-Care-Standards

Last Accessed: August 21, 2026

Strength of Recommendation: B (Evidence from randomized controlled trials with an identified flaw that may limit validity of the results Supportive evidence from well-conducted cohort studies.)

Shoe inserts are frequently prescribed to counteract shear and friction caused by the foot sliding against the sole of the shoe [22]. Reducing pressure on the plantar surfaces of the feet and under the metatarsal heads is of prime importance [16].

When deciding on appropriate footwear, the patient's lifestyle (e.g., occupation, sports activities, general environment/climate) should be taken into consideration. If shoes are not practical, they will not be worn, no matter how much benefit they provide. Often overlooked, it is also important to consider the cosmetic appeal/acceptability of the footwear. Patients may refuse to wear anything that draws attention to the need for adaptive footwear. It is important not to lose sight of the therapeutic value of feeling good about one's appearance and the relevance it has in the lives of those coping with a chronic disease.

Alcohol Use and Smoking

Alcohol and tobacco use are important modifiable factors in the management of diabetic neuropathy. Chronic heavy alcohol consumption can independently cause peripheral neuropathy, worsen glycemic control, and contribute to nutritional deficiencies that may further impair nerve function. Smoking promotes vascular dysfunction and is strongly associated with peripheral arterial disease, impaired wound healing, and an increased risk of diabetic foot complications. Patients with diabetic neuropathy should be counseled to avoid or substantially reduce heavy alcohol use and to stop smoking as part of a comprehensive treatment plan that includes glycemic management, symptom control, and preventive foot care [14,23].

Pain Management

For patients with painful diabetic neuropathy, pharmacologic therapy can reduce pain and improve quality of life, although available treatments generally do not restore normal nerve function. Recommended options include pregabalin, duloxetine, or gabapentin, while other medications, including certain tricyclic antidepressants, may be considered in selected patients. Treatment should be individualized based on symptom severity, comorbidities, potential adverse effects, drug interactions, and patient preferences. Opioids are generally not recommended for the routine treatment of painful diabetic neuropathy because of their limited long-term benefit and risks associated with chronic use [21].

Pulsed electromagnetic field (PEMF) therapy is a noninvasive modality that has been investigated as an adjunctive treatment for painful diabetic peripheral neuropathy. Some clinical trials have reported reductions in neuropathic pain, including a randomized, sham-controlled trial demonstrating approximately a 30% reduction in pain among patients receiving active treatment [14]. However, evidence remains limited, and systematic reviews have not established consistent benefits across peripheral neuropathies [14].

PERIPHERAL VASCULAR DISEASE

Neuropathy and PAD can produce different, but overlapping, foot findings. Autonomic neuropathy may cause reduced sweating and dry, cracked skin, whereas peripheral arterial disease may produce cool skin, diminished pulses, pallor with elevation, and dependent rubor. Because these conditions frequently coexist, a comprehensive diabetic foot examination should assess both neurologic and vascular status.

Diabetes accelerates atherosclerotic disease through multiple mechanisms, including endothelial dysfunction, chronic inflammation, oxidative stress, and metabolic abnormalities [16,21]. These processes contribute to arterial narrowing and reduced blood flow to the lower extremities. The risk of PAD increases with age and longer duration of diabetes and is further increased by cigarette smoking, hypertension, dyslipidemia, poor glycemic control, neuropathy, retinopathy, and a history of cardiovascular disease [25].

Clinical Signs/Symptoms

When tissue perfusion is inadequate, the foot may become cool, pale with elevation, or exhibit dependent rubor, and wounds may heal poorly. However, PAD may be asymptomatic, and the absence of classic intermittent claudication does not exclude the disease.

Although claudication and resting pain are classic symptoms of peripheral arterial disease, they may be missing in the patient with diabetes who has sensory neuropathy [16]. If these symptoms are present, they are indicative of the need for aggressive re-vascularization [16]. However, in more than 60% of lower extremity amputations there is no attempt at re-vascularization prior to the amputation [26].

Individuals with diabetes and PAD are at much higher risk of developing serious foot ulcerations and infections [21]. If both neuropathy, and PAD are present in the patient with diabetes then the risk of ulceration, infection and amputation are even higher [21]. Diabetic foot ulcers—like all wounds—require oxygen and leukocytes to heal. In the presence of poor circulation there is impaired delivery of oxygen and leukocytes to the wound [25]. This in turn, not only prevents healing, it also promotes the growth of anaerobic organisms, which are difficult to eradicate from the wound and increases the likelihood of amputation [25].

Treatment

If ischemia is present on noninvasive testing, the patient will need an arteriography study done by endovascular surgeon or by an interventional radiologist [16]. During this procedure, detailed views of the circulation to the foot can be obtained [16]. Compromised circulation can be corrected by a revascularization procedure, and studies demonstrated that these procedures have good success rate among patients with diabetes [16].

One cause of circulatory compromise is blockage in an artery. Angioplasty accompanied by stent placement may be warranted to ensure that the artery remains open [18].

CHARCOT FOOT

Charcot foot, also known as Charcot arthropathy or neuropathic joint disease, affects the bones and soft tissue of the ankle and foot and leads to dislocations, acute fractures, and joint destruction [27]. Charcot foot is a common occurrence among patients with diabetes, and those with a Charcot deformity and a diabetic foot ulcer are 12 times more likely to have an amputation than those without Charcot [27].

Charcot foot is caused by a sudden increase in the blood flow to the affected area, leading to redness, swelling, and an increase in the rate of bone re-absorption [28]. It has been described as a foot with crumbling bones [29]. The areas most frequently affected are the middle of the foot joints, the area of the foot in front of the ankle, and the ankle joint [28].

Clinical Signs/Symptoms

The early symptoms of a Charcot foot are not always easily detected [16]. The condition may start with mild swelling, erythema, and an elevation of the skin temperature in the affected foot and ankle [16]. Charcot foot can also have a gradual onset, and it is a condition that must be watched closely for in all people with diabetes. Left untreated, it can cause permanent foot deformities, which in turn leads to an abnormal distribution of pressure on the plantar surface of the foot [30].

An acute Charcot foot can be mistaken for cellulitis, acute gouty arthritis, or thrombophlebitis [16,29]. A hot, red, swollen foot in a person with diabetes and peripheral neuropathy should be presumed to have acute Charcot arthropathy until it has been appropriately evaluated. The absence of significant pain does not exclude a serious underlying process. Persistent erythema, systemic symptoms, an open wound, elevated inflammatory markers, or other evidence of infection should increase concern for cellulitis or osteomyelitis. If swelling and redness abates with elevation of the affected extremity, Charcot foot is more likely than infection.

A patient with diabetes and a red, hot foot should have x-ray studies ordered to evaluate for possible changes in the underlying structures [21]. A positive Charcot deformity can be seen on x-ray as multiple fractures of the small bones of the foot [21].

Treatment

Early recognition and treatment of Charcot arthropathy is the key to minimizing foot deformity, and disfiguration [21]. Treatment of this condition aims at decreasing or, if possible, eliminating weight bearing on the affected foot. Careful attention to providing proper footwear is essential because of the altered shape of the foot [21]. Put simply, shoe shape should match foot shape.

In some instances, a total contact cast may be applied to the affected extremity to achieve complete non-weight bearing [28]. This is a hard cast that will incorporate the patient's toes and end just below the patient's knee.

4. GENERAL APPROACHES TO DIABETIC FOOT CARE

Most do not give much thought to their feet, but those with diabetes cannot afford this luxury. For these patients, good foot care is an essential part of their lives. The American Diabetic Association recommends that individuals with diabetes have at least one foot exam yearly; those diagnosed with diabetic neuropathy require even more frequent screening [19]. The goal for all people with diabetes is to prevent foot injury.

Unfortunately, foot exams for patients with diabetes are often not routine in primary care settings, with foot exams done during 10% to 23% of diabetic care check-ups [21]. Foot screening programs play a role in reducing lower extremity amputations in the diabetic populations, and early identification of patients at risk for foot ulceration allows for earlier intervention and protective care.

MULTIDISCIPLINARY DIABETIC FOOT TEAM

The diabetic foot team is multidisciplinary and includes diabetes educators, dieticians, podiatrists, pedorthists, infectious disease specialists, wound care professionals, social workers, and mental health providers [31]. Many times, the team will also include the endocrinologist involved in managing the patient's diabetes.

All individuals with diabetes should see a podiatrist at least once every year [18]. As part of their patient care, podiatrists will trim toenails, treat ingrown toenails, remove calluses/corns, and, if needed, perform surgery on the bones of the foot and ankle (e.g., hammertoe correction, bunion removal) [18].

The most important member of the team is the patient, and the goal of care is to empower them to take charge of their own foot health. Family members and the patient's support system will also play an important role, especially if the patient is unable to perform routine foot care and daily foot inspections.

Nurses play a major role in providing foot examinations and in educating patients and families in preventive care and lifestyle changes. Certified diabetes educators are registered nurses who have specialized skills and training in providing diabetic education. However, all nurses who work with patients with diabetes and their families are educators. Patient and family education that targets appropriate foot care can help to reduce the incidence of ulcer development in high-risk patients with diabetes [21]. Studies have demonstrated improved outcomes when education is coupled with regular podiatry care [16].

It is important not to assume that because a patient has lived with people with diabetes for years that there is no need for diabetic education. All patients with diabetes should be assessed for knowledge deficits, misconceptions about their care, and outdated information.

HOLISTIC APPROACH TO DIABETIC FOOT CARE

During the initial examination, the patient's complete medical history should be reviewed. One key point to note is whether the patient is undergoing renal dialysis or is post-transplant [16]. Other important components that need to be noted are a previous history of diabetic foot ulceration, an amputation, joint deformity, cigarette use, and prior angioplasty [16].

Many patients with diabetes have been prescribed several medications to control their diabetes and other comorbidities. While reinforcing the changes they need to make, and sustain, to optimize a healthy lifestyle, it is important that education related to insulin therapy remain positive. Insulin should never be made to sound as a punishment for the patient's failure to maintain a healthy lifestyle [21]. Many patients fear having to self-administer insulin shots or having to deal with an insulin pump, and reassurance and support can help ensure compliance.

A psychological assessment is a vital part of the holistic approach to the care and treatment of the patient with a diabetic foot ulcer [7]. Diabetes is a chronic, progressive disease, and it can be overwhelming for patients. There is the challenge of ongoing glucose monitoring, maintaining quality of life, and self-management issues. Diabetes-related stress, which is different from clinical depression, is a common finding among those with diabetes and their significant others [7]. Maintaining emotional and psychological well-being should be a proactive part of plan of care for each patient. If the patient and/or family are unable to maintain self-care and there are concerns about the level of anxiety present, a referral to a mental health specialist who has experience with diabetes management is warranted [7].

THE FOOT ASSESSMENT

Foot assessment should take place in a well-lit, private area and should include evaluation of the protective sensation, skin integrity, and vascular status. All foot and ankle coverings, including sheer stockings, should be removed.

Diabetic Foot Deformities

The feet should be carefully examined for deformities (i.e., any alterations in the normal shape of the foot) and callous formation [18,21]. Charcot foot can usually be identified by its shape, frequently with medial protrusion and a flat foot. Other deformities to look for are hammertoes (i.e., toes pulled out of their normal positions, usually due to motor neuropathy), claw toes, and bunions [32]. Corns are often noted developing over prominent toe joints; however, they can also occur between the toes (referred to as soft corns or kissing corns). These corns are the result of the bones in adjacent toes rubbing against each other [18]. Shoes that cramp toes tightly together can aggravate corns and can lead to skin breakdown, ulcer formation, and subsequent infection [18].

Skin Inspection

Skin inspection of both feet should include noting skin color, particularly unilateral redness, may indicate the beginning of Charcot arthropathy. Skin thickness, dryness, and cracking should also be noted [16].

It is important to remember to check between the patient's toes and under the metatarsal heads [18]. Patients with diabetes and peripheral neuropathy often lose the protective fat pads over the boney prominences in their feet [18]. They are also at increased risk for fungal infections, and tinea pedis (athlete's foot) is a common problem. Fissures and cracks in the interdigital spaces are another common problem and should be carefully checked [21].

Toe and Toenail Problems

The importance of keeping the spaces between the toes clean and dry should be stressed to the patient. If a build-up of moisture in these areas is a concern for the patient, small strips of lamb's wool may be placed between the toes and change daily, although pressure and shear should be cautioned against. Because fungal infections are contagious, advise patients not to share nail clippers with other members of their household [18].

Patients with diabetes frequently have problems with ingrown toenails. In the absence of peripheral neuropathy, this is a painful condition, but a lack of pain sensation can result in the condition becoming more severe before treatment is sought and infection is a concern. Patients with diabetes and an ingrown toenail should see a podiatrist to correct the problem rather than attempting to address it themselves [30].

Callus Formation

Calluses should be checked for hemorrhaging [16]. Calluses and corns should be carefully paired back or removed to reduce pressure on the underlying tissue. However, the patient should be warned not to attempt to do this at home. Instead, callus and corn removal should be done by a podiatrist during a diabetic foot examination. The podiatrist may also recommend that the patient use a silicone rubber splint to provide cushioning underneath cramped toe joints as a preventive measure.

Loss of Protective Sensation

Checking for loss of protective sensation is a cornerstone of the diabetic foot exam. The most common tests used in this assessment are [16]:

- 10-g monofilaments

- 128-Hz tuning fork

- Ankle reflex testing

- Pinprick sensation

- Vibration perception threshold testing

At least two of these tests should be routinely done during a diabetic foot screening [16].

Monofilament Testing

Evidence Based Practice Recommendation

The American Diabetes Association recommends that all people with diabetes should have annual 10-g monofilament testing to identify feet at risk for ulceration and amputation.

https://diabetesjournals.org/care/article/49/Supplement_1/S261/163919/12-Retinopathy-Neuropathy-and-Foot-Care-Standards

Last Accessed: August 21, 2026

Strength of Recommendation: B (Evidence from randomized controlled trials with an identified flaw that may limit validity of the results Supportive evidence from well-conducted cohort studies.)

The 10-g Semmes-Weinstein monofilament test is a widely recommended clinical tool for detecting loss of protective sensation and identifying patients at increased risk for diabetic foot ulceration [24]. Studies have proven that loss of pressure sensation using a 10-gauge monofilament is indicative of high risk for ulcer development [16]. It is a non-invasive test, simple to learn, and easily implemented.

To begin, the patient removes their shoes and socks and is seated in a comfortable position, with their legs and feet extended. The test is explained to the patient, and the monofilament is applied to the back of their hand or arm, so that they are aware of how the sensation feels. The patient is then asked to close their eyes, and the examiner is careful not to touch the patient's foot with his/her hand. The patient is asked to say "yes" whenever they feel the pressure of the monofilament on their foot.

In general, ten sites on the patient's foot are tested [21]:

- The plantar surfaces of the first, third, and fifth toes

- The plantar areas of the first, third, and fifth metatarsal heads

- The medial and lateral plantar surfaces of the mid-foot

- The plantar heel

- The dorsal mid-foot

During the test, enough force is applied to the monofilament to cause the wire to bend into a c-shape [21]. The normal response time is less than three seconds; greater than three seconds is considered a delayed response indicating some degree of neuropathy. A negative response (i.e., failure to sense the filament) at any of the test sites identifies loss of protective sensation in that area and suggests increased risk for ulceration [32].

128-Hz Tuning Fork Test

Another frequently done test to evaluation sensation is the 128-Hz tuning fork. This simple and inexpensive test checks for vibratory sensation, and it is done over the tips of the hallux [16]. The result is considered abnormal if the patient is unaware of the vibratory stimulation from the tuning fork while the person performing the test can detect it [24]. This test assesses early sensory loss, but it does not evaluate the degree of sensory loss present [24].

Circulation and Peripheral Pulses

As discussed, peripheral vascular disease is a major contributory factor to diabetic foot ulcers and can contribute to impaired wound healing. Adequate circulation to the feet should be assessed during every diabetic foot examination [18].

During the examination, the femoral, popliteal, and dorsalis pedis and posterior tibial artery pulses should be palpated [16]. Normally, clearly palpable posterior tibialis and dorsalis pedal pulses are a positive indication of adequate circulation [16].

In all patients where foot pulses are not palpable, non-invasive testing should be ordered to further evaluate circulation [16]. An ankle-brachial index is an indirect measurement of arterial circulation to the feet. It is often recommended as a baseline test for people with diabetes older than 50 years of age [18]. Normal results are in the range of 0.9 to 1.1 [31]. A frequent occurrence in patients with diabetes are noncompressible arteries and ankle-brachial index readings of 1.2 and higher [31].

EDUCATION RELATED TO DIABETIC FOOT CARE

Education related to care of the diabetic foot should begin soon after the patient is diagnosed with diabetes and should be reviewed and reinforced with every patient encounter. Diabetes education in its entirety is a very broad topic and focuses on many body systems; the importance of diabetic foot care can easily be overlooked.

In some cases, patients with diabetes may not connect problems with their feet to diabetes, and this is one of the challenges for those involved in diabetes education. Patients may indicate that they are comfortable with their knowledge of their medications/insulin and dietary restrictions, but information related to foot care and risks is often sketchy or incomplete.

Instructions for Diabetic Foot Care

Diabetic foot education should begin with the following instructions to patients [18,34,35]:

- Check your feet every day for cuts, bruises, blisters, or swelling. A good time to do this is when you take your shoes off at the end of the day.

- If you cannot see the soles of your feet, use a long-handle mirror or have someone else do the inspection for you.

- Wash your feet every day. Dry them carefully, paying special attention to the areas between your toes. Do not soak your feet, as this can lead to dry skin.

- Rub a small amount of a hydrating skin lotion into your feet after washing and drying. However, do not rub lotion between your toes. Choose a lotion that is alcohol free, because as alcohol evaporates it causes drying of the skin.

- Use cornstarch or talcum powder between the toes, but do not use so much that it cakes.

- Never go barefoot, even in your own home. Something as small as a sesame seed can cause enough pressure to start a foot ulcer. The only times you should not have protective footwear on is when you are bathing or in bed.

- Choose seamless, lightly padded socks. Avoid tightly fitting socks. (Patients can buy specially made diabetic socks. They usually provide cushioning and reverse stitching on the toe seams to avoid friction and shear.)

- Do not place elastic garters or rubber bands around your legs.

- Protect your feet from heat and cold. Never put your feet into hot water. Use your hand to check the temperature of water before putting your feet into it.

- Shake out shoes before putting them on, and feel along the inside of shoes for small hard objects that could cause pressure.

- Make sure that the lining inside shoes or slippers is smooth and wrinkle free.

- When sitting, put your feet up. Do not keep your legs crossed for long periods of time.

- Practice wiggling your toes two to three times daily for about five minutes.

- Avoid plastic or vinyl shoes, as they do not stretch or allow for air flow.

- If you are wearing soft inserts in your shoes, these will need to be replaced three times yearly.

Advise the patient to make these simple steps part of their daily routine, similar to showering or brushing their teeth.

5. DIABETIC FOOT ULCERS

A diabetic foot ulcer is defined as a lesion that penetrates through the dermis of the foot [16]. As discussed, foot ulcerations are a serious complication of diabetes [36]. These ulcers result in discomfort, disability, and a decrease in the quality of life, and they are the most common cause of hospitalization among individuals with people with diabetes [14,36].

It is estimated that around 15% of people diagnosed with diabetes will develop at least one diabetic foot ulcer during their lifetime [37]. These ulcers are a leading cause of lower extremity amputations and osteomyelitis in the United States; 85% of all lower extremity amputations in the diabetic population are directly related to the presence of a diabetic foot ulcer [16,36]. In total, approximately 10% of all patients with diabetes will endure some form of amputation during their lifetime, and toe and partial foot amputations are the most common [18].

ASSESSING A DIABETIC FOOT ULCER

Assessment of a diabetic foot ulcer should follow the same protocol for the assessment of all wounds. At least once every week, the wound should be measured and the findings recorded. Assessment of extent of the wound should be done using sterile cotton swabs.

These weekly assessments will help to monitor the wound status and the effectiveness of the treatment plan. If after four weeks there is no noticeable improvement in the wound, as evidenced by decrease in wound size, necrotic tissue, and/or slough, then the treatment plan should be reviewed by the clinical team and the patient. The longer a wound persists, the more difficult it becomes to heal [25]. The amplitude of healing (i.e., size decrease) of a diabetic foot ulcer at four weeks is a reasonable indicator of healing at the 12-week mark [38].

Ulcer location should be carefully evaluated in order to determine the initial cause of the ulcer and where off-loading should be applied [16]. Frequently, ulcers are found under or surrounded by a callus [18]. The visible surface of the ulcer may only be a few centimeters, but this in many instances is only the "tip of the iceberg," and the actual tissue damage beneath the skin surface can be quite extensive.

The wound will be gently probed for undermining and tunneling, and these should be recorded using the face of the clock as a guide. Examples of appropriate documentation include "tunneling to a depth of 4 cm at 3 o'clock" or "undermining from 6 o'clock to 10 o'clock to a depth of 5 cm." Documentation of the wound bed should include the type of tissue present and the amount (e.g., 50% brown necrotic tissue, 50% gray adherent slough). Any odor and drainage should be noted, including quality and amount. The periwound area should also be assessed, with documentation of the quality and integrity of the skin and the impact, if any, of drainage, undermining, tunneling, and dressings.

CLASSIFICATION

The most widely used classification system for diabetic foot ulcers is the Wagner Ulcer Scale. The Wagner Scale is divided into six different grades [25]:

- 0: No open wounds. Healed ulcer sites and bony deformity may be present. The patient is at high risk for ulcer development.

- 1: Superficial ulcer

- 2: The wound extends through subcutaneous tissue, with exposure of underlying structures (e.g., joint capsule, tendon, bone).

- 3: Abscess formation, osteitis, or osteomyelitis

- 4: Gangrene of a toe or forefoot

- 5: Gangrene of the entire foot, requiring amputation

The possibility of osteomyelitis (bone infection) should be considered with all Wagner 2 diabetic foot ulcers. If there is suspicion of ulcer infection, an x-ray should be done. However, radiological changes associated with osteomyelitis may not be evident for several weeks post-infection and a negative x-ray does not rule out the possibility of osteomyelitis [16]. MRIs are regarded as the most definitive test for diagnosing osteomyelitis in diabetic foot ulcers. A bone biopsy will also provide an accurate diagnosis [16].

HEALING DIABETIC FOOT ULCERS

The two most important components in healing diabetic foot ulcers are adequate circulation and pressure relief. The first and possibly most important approach in the treatment of diabetic foot ulcers is off-loading [22,39]. This results in pressure being dispersed over a wider area of the foot and reduces the burden of mechanical stress on the wound, which is essential for healing [16].

Off-Loading

Off–loading can be achieved by applying either a removable or nonremovable device to the extremity [39]. Frequently used methods to off-load the diabetic foot are [21]:

- Bed rest

- Wheelchair

- Total contact casting

- Crutches

- Felted foam (soft contact casting)

- Half-shoes

- Custom-made splints

- Removable cast walkers

Reducing pressure and shear forces at the ulcer site allows tissue to heal and helps prevent continued trauma to the wound. There is some evidence that off-loading with nonremovable devices achieves a higher level of healing than with removable devices [39]. Current guidelines recommend a nonremovable knee-high offloading device as the first-choice treatment for a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes. A total contact cast (TCC) or a nonremovable knee-high walker may be used, with the choice based on available resources, clinician expertise, patient-specific factors, and acceptability.

Total Contact Casting

A TCC is a customized, minimally padded cast that closely conforms to the contours of the foot and lower leg. By redistributing plantar pressure and limiting movement of the foot, it substantially reduces mechanical stress on the ulcer. TCC has been extensively studied and remains an effective method for promoting healing of appropriately selected diabetic plantar foot ulcers. Importantly, the effectiveness of a TCC depends on appropriate patient selection, skilled application, and close monitoring for cast-related complications [16,40].

Patients receiving a TCC require regular follow-up to assess the ulcer, surrounding skin, edema, and overall tolerance of the cast. The cast may need to be changed or reapplied as edema decreases or if complications develop. Close monitoring is particularly important because patients with peripheral neuropathy may not recognize pressure-related injury or other complications.

Nonremovable Knee-High Walkers and Instant Total Contact Casts

A nonremovable knee-high walker provides another evidence-supported option for offloading a neuropathic plantar ulcer. A removable cast walker can also be converted into an instant total contact cast (iTCC) by securing the device so that the patient cannot readily remove it. This approach combines the pressure redistribution of a knee-high walker with the adherence advantage of a nonremovable device [41].

One important advantage of nonremovable devices is that they enforce adherence. With a removable device, patients may remove the device for convenience or during ambulation, thereby reducing the amount of time the ulcer is actually offloaded. Current evidence and guidelines therefore favor nonremovable knee-high devices over removable devices when they are tolerated and not contraindicated [16,41].

Removable Cast Walkers

When a nonremovable knee-high device is contraindicated or not tolerated, a removable knee-high or ankle-high offloading device may be used as a second-choice approach. Patients should be instructed to wear the device during all weight-bearing activities, because inconsistent use can substantially reduce its effectiveness [16].

Removable devices offer practical advantages, including the ability to remove them for wound care, bathing, and examination. However, these advantages must be balanced against the potential for inconsistent adherence.

Other Offloading Approaches

When a nonremovable or removable knee-high device cannot be used or is unavailable, other approaches may be considered depending on the location and characteristics of the ulcer. These may include appropriately fitted footwear combined with felted foam or other pressure-relieving interventions. For selected ulcers that do not heal with conservative offloading, surgical offloading procedures may also be considered.

DEBRIDEMENT AND WOUND BED PREPARATION

Wound debridement is a critical step in the treatment of diabetic foot ulcers [25]. The purpose of debridement is to remove slough, necrotic tissue, and biofilm from the wound bed and to activate the process of wound healing [42]. Wound-bed preparation involves removing calluses, necrotic tissue, slough, and other nonviable material that may impede healing, while addressing the underlying factors contributing to the ulcer. Current guidelines recommend that diabetic foot ulcers be regularly assessed and that nonviable tissue and surrounding callus be removed, preferably using appropriate sharp surgical instruments.

Several methods of debridement are available, including sharp or surgical debridement, mechanical debridement, enzymatic debridement, autolytic debridement, and biological debridement. Sharp debridement is commonly preferred because it allows the clinician to selectively remove devitalized tissue and callus and can rapidly produce a cleaner wound bed [16]. However, high-quality evidence comparing different debridement methods remains limited, and the choice of technique should be individualized according to the characteristics of the wound, the patient's condition, available expertise, and potential contraindications.

Sharp debridement may be performed in an outpatient or other appropriate clinical setting when the wound can be safely managed there. More extensive wounds, wounds with significant infection or necrosis, or wounds requiring deeper surgical intervention may require management in an operating room or by a multidisciplinary foot-care team. The depth and extent of debridement should be determined by the location and characteristics of the wound and the amount of nonviable tissue present [16].

Debridement should be repeated as clinically indicated rather than automatically according to a fixed schedule. The frequency of debridement depends on the amount and type of devitalized tissue, surrounding callus, exudate, infection, wound progression, and the patient's tolerance. A randomized study in selected patients with diabetic foot ulcers found similar healing outcomes with weekly and every-other-week sharp debridement, illustrating that more frequent debridement is not necessarily required for every patient [43].

Enzymatic and other nonsurgical methods may have a role in selected circumstances, but evidence supporting their routine use in addition to standard care is limited. The International Working Group on the Diabetic Foot found insufficient evidence to recommend enzymatic, autolytic, biosurgical, hydrosurgical, chemical, or laser debridement over standard care that includes appropriate sharp debridement [44].

Debridement alone is not sufficient to heal a diabetic foot ulcer. Optimal management also requires appropriate offloading, assessment and treatment of infection, evaluation and treatment of peripheral arterial disease when present, appropriate wound dressings, and optimization of diabetes and other comorbidities. The American Diabetes Association identifies debridement of hyperkeratotic, necrotic, or nonviable tissue, offloading, revascularization when necessary, infection management, and appropriate dressings as fundamental components of diabetic foot-ulcer treatment [7].

INFECTION AND THE DIABETIC FOOT ULCER

Diabetic ulcers appear to be more prone to bacterial growth, in part due to the higher level of glucose in the wounds [45]. This again emphasizes the importance of monitoring and controlling blood glucose levels in patients with diabetes with open wounds.

The occurrence of infection in the diabetic foot ulcer is one of the leading causes of limb amputation [16]. Wound infection frequently spreads to the deeper tissues and bone [46]. When the infection is deep in the tissues, the expected signs of infection may be absent—there may be little or no elevation in white cell count, erythrocyte sedimentation rate, or body temperature [16]. This is an important fact to keep in mind; patients with diabetic foot ulcers may not exhibit the classical signs of infection [25]. In fact, fewer than one-third of patients with osteomyelitis in a diabetic foot ulcer have a raised temperature or an elevated white cell count [25].

Biofilm formation is also an important consideration in wound treatment. Biofilm formation is a symbiotic relationship between several bacteria binding together to form a matrix that adheres to the wound bed and is highly resistant to standard means of treatment. The layer of extracellular polysaccharides produced by the biofilm bacteria provides a defense against antibiotics and the patient's immune system [45]. It is estimated that approximately 60% of chronic wounds have a biofilm layer in the wound bed, compared with 6% of all acute wounds [45].

The IWGDF/IDSA classification categorizes infection according to its severity [31]. A mild infection involves at least two local signs of inflammation with erythema extending no more than 2 cm beyond the wound margin and no systemic manifestations. A moderate infection involves deeper tissues and/or erythema extending 2 cm or more beyond the wound margin, without systemic inflammatory response. Severe infection is characterized by local infection accompanied by systemic manifestations of infection.

Mechanism of Wound Healing

Wound healing typically proceeds in well-defined stages; however, patients with diabetic foot ulcers are at increased risk for developing chronic wounds, which stall in the inflammatory phase of wound healing and are unable to progress any further [16]. Growth factors are necessary component of wound healing, and research findings show that patients with diabetes and ulcers produce fewer growth factors than those without diabetes.

Early Symptoms and Signs of Infection

An unexplained increase in blood glucose may sometimes accompany infection and can be an important clinical clue in a person with diabetes [25]. Infection and other acute illnesses can cause hyperglycemia through increased insulin resistance and the release of counter-regulatory hormones. However, elevated blood glucose is nonspecific and should not be used alone to diagnose a diabetic foot infection. Because peripheral neuropathy may reduce pain and other inflammatory symptoms, clinicians should carefully examine the foot for local signs of infection, including new or increasing swelling, erythema, warmth, tenderness, induration, or purulent drainage [16].

Culturing Diabetic Foot Ulcers

Evidence Based Practice Recommendation

In a person with suspected soft tissue diabetic foot infection, the International Working Group on the Diabetic Foot (IWGDF) and the Infectious Diseases Society of America (IDSA) recommends considering a sample for culture to determine the causative micro-organisms, preferably by aseptically collecting a tissue specimen (by curettage or biopsy) from the wound.

https://www.idsociety.org/practice-guideline/diabetic-foot-infections/

Last Accessed: August 21, 2026

Strength of Recommendation/Level of Evidence: Conditional/moderate

Deeper infections, defined as those down to and including the bone, pose a serious risk of limb amputation, and hospitalization is required for these patients, with immediate surgical debridement, drainage of the wound, and the commencement of IV antibiotics [25]. To determine the causative organism(s) in diabetic wounds, deep tissue cultures should be performed, rather than swabbing the wound surface [25]. Tissue cultures should be obtained after debridement has been done and tested for both aerobic and anaerobic organisms [31]. Any individual who presents with a diabetic foot ulcer that extends down to bone should be evaluated immediately for possible osteomyelitis.

However, a positive wound culture alone does not establish infection because diabetic foot ulcers are frequently colonized by bacteria. Culture results should be interpreted in conjunction with the clinical findings and used to help guide antimicrobial therapy.

Treatment

Management of a diabetic foot infection should be based on the clinical severity, depth and extent of infection, presence of ischemia or necrosis, suspected or confirmed osteomyelitis, previous antimicrobial exposure, and patient-specific factors. Depending on the severity and complexity of the infection, management may involve primary care, podiatry, wound care, infectious disease, vascular surgery, and other surgical specialists [33].

Antibiotics should not be used to treat a clinically uninfected diabetic foot ulcer or simply to promote wound healing [31]. Instead, antibiotic therapy should be reserved for wounds with clinical evidence of infection.

Mild infections can often be managed with oral antibiotics on an outpatient basis, provided the patient is clinically stable and there are no factors requiring hospitalization or surgical management [31]. Antibiotic selection should be based on the severity and likely pathogens, previous microbiologic results, recent antibiotic exposure, allergies, renal function, local resistance patterns, and other patient-specific considerations. Empiric treatment of a mild infection in a patient who has not recently received antibiotics generally does not need to provide broad-spectrum coverage for multiple resistant or unusual organisms.

For moderate or severe infections, deeper infection, extensive tissue involvement, significant ischemia, or suspected osteomyelitis, more extensive evaluation and treatment may be necessary. As noted, hospitalization and intravenous antibiotics may be appropriate in selected patients.

Osteomyelitis should be considered when infection is deep, prolonged, recurrent, or associated with exposed or palpable bone. Initial evaluation may include a probe-to-bone test, plain radiographs, and inflammatory markers such as ESR and CRP. MRI may be appropriate when the diagnosis remains uncertain after clinical examination, plain radiographs, and laboratory testing. When osteomyelitis is suspected, obtaining an appropriately collected bone specimen for culture may be necessary to guide treatment.

Some diabetic foot infections require surgical as well as antimicrobial treatment. Surgical intervention may be necessary to drain an abscess, remove necrotic or infected tissue, excise infected bone, or control a rapidly progressing infection. Urgent surgical consultation should be obtained for conditions such as necrotizing infection, deep abscess, compartment syndrome, extensive gangrene, or severe ischemia [31]. Early surgical intervention may also be appropriate for selected moderate or severe infections to remove infected and necrotic tissue and control the source of infection.

The extent of surgery depends on the location and severity of infection and the amount of viable tissue that can be preserved. Procedures may range from incision and drainage or limited debridement to removal of infected bone or partial foot amputation. Major lower-extremity amputation is generally reserved for situations in which infection, ischemia, or extensive tissue destruction cannot be adequately controlled while preserving a functional limb.

CHOOSING SUITABLE DRESSING AND TOPICAL TREATMENT

As in all wound care, maintaining a moist wound environment is critical to healing. While protecting the wound from infection and trauma, a moist environment also promotes the growth of granulation tissue and epithelial formation. When choosing an appropriate dressing for a diabetic foot ulcer, one important factor is the amount of exudate. If there is excessive drainage, an absorbent dressing will be necessary. If the wound bed somewhat dry, it will require a dressing that will donate moisture to the wound while not sticking. Consideration should also be given to reducing pain while the dressing is in place and at dressing changes, and improving the overall quality of life for the patient [14].

Another factor is the length of time the dressing can remain in place and how effectively it can protect the periwound area from maceration, sheer, and friction damage [31]. Collagen-based dressings are often a good choice for healing, as they counteract inflammatory substances that lead to the breakdown of newly formed granulation tissue and promote the migration of fibroblasts into the wound and the growth of collagen fibers [20].

Factors that may impact the cost to the patient may also be part of the decision-making process, including the cost of the product, frequency of dressing changes, evidence-based research that demonstrates healing rates, and nursing time required to carry out dressing changes [31].

The application of topical antimicrobials to the wound bed has been shown to reduce bacterial count in granulating tissue [31]. Silver dressings are one option, as silver has proven to be an effective antimicrobial agent [45]. Topical growth factors have also been shown to advance healing in diabetic foot ulcers [20]. Before application, it is important to ensure that the wound is free from infection.

ADJUNCTIVE TREATMENT OPTIONS

Hyperbaric Oxygen Therapy

One of the advanced modalities used in the treatment of diabetic foot ulcer is hyperbaric oxygen therapy. Because all wounds require oxygen to heal, the therapeutic value of hyperbaric oxygen therapy is to increase the amount of oxygen available to the wound bed. Hyperbaric oxygen therapy is administered in a specially designed pressurized chamber. During the treatment, the patient breathes 100% oxygen, which results in increased oxygen delivery to the wound bed. This stimulates collagen growth and the proliferation of fibroblasts [38]. Evidence supporting the use of this modality is limited, and it is generally considered an adjunctive treatment of non-healing foot ulcers.

Negative Pressure Wound Therapy

Negative pressure wound therapy also provides beneficial therapy for wound healing, and granulation tissue formation, by removing fluid from the wound bed, decreasing edema, and stimulating small blood vessels to dilate which increases local wound circulation [14]. Current evidence suggests that negative pressure wound therapy may improve healing outcomes in certain diabetic foot wounds, particularly postoperative wounds, but its use should be individualized according to wound characteristics and patient needs.

Cellular and Tissue-Based Products

Cellular and tissue-based products (CTPs), sometimes referred to as skin substitutes, are a heterogeneous group of advanced wound-care products that may provide structural or biologic support to selected chronic wounds. Products used in diabetic foot ulcers include cellular and acellular products derived from human or animal tissue, among other materials. Because these products differ substantially in composition, mechanism, and evidence of effectiveness, results from one product or product category should not be generalized to all CTPs [44].

CTPs should not replace the fundamental components of diabetic foot-ulcer management. Before considering an advanced wound therapy, clinicians should ensure that the wound is appropriately prepared, including adequate debridement of nonviable tissue and callus, appropriate management of infection, adequate offloading, and assessment and management of peripheral arterial disease when present.

Some CTPs have demonstrated potential benefits in clinical studies, but the evidence is heterogeneous and generally of low certainty. The IWGDF therefore recommends against routine use of cellular or acellular skin substitutes as adjunctive therapy for diabetic foot ulcers [44]. Selected products, including certain placental-derived products, may be considered when appropriate standard care has failed and the necessary expertise and resources are available.

The decision to use a CTP should be individualized according to the characteristics of the ulcer, vascular status, infection status, response to standard care, available evidence for the specific product, and applicable regulatory and reimbursement requirements.

ACHIEVING FINAL WOUND CLOSURE

After there is growth of healthy granulation tissue in the wound and wound depth is no longer an issue, wound closure must be achieved. The longer the wound is open, the greater the risk of infection and wound deterioration. Different surgical flaps can be used to close the wound, including rotational and free flaps [20].

RE-OCCURRENCE OF DIABETIC FOOT ULCERS

Re-occurrence of diabetic foot ulcers is a major problem, with approximately 40% of patients who have successfully healed a diabetic foot ulcer experience another ulcer within one year, increasing to approximately 65% within three years [16,44]. The use of custom-made footwear appears to play a protective role in preventing additional ulceration [16]. After a diabetic foot ulcer has healed, the patient should not go back to wearing the shoes (or similar shoes) that they were wearing at the time the ulcer developed. Regular shoes are not made to accommodate irregularities in foot shape and at-risk pressure points.

There is a great deal of evidence that supports the fact that optimum glycemic control is the cornerstone of prevention and progression of diabetic complications, including diabetic foot ulcers [25]. In addition, persons with a history of foot ulceration should increase foot examination frequency to every one to three months, and their feet should be inspected at every healthcare visit [7].

AMPUTATION

Amputation is a considerable risk with diabetic foot ulcers, and a diabetes-related limb amputation is estimated to occur every 30 seconds [16]. Mortality rates following major amputation are higher than many major cancers, with an even higher five-year mortality rate in diabetic amputations [16]. In response, limb salvage programs have become more common across the country.

Patients who have had an amputation are at increased risk for ulceration, infection, and amputation of the remaining limb, as neuropathy and vascular disease will occur bilaterally in most cases [15]. Up to 20% of those who have had a diabetic foot ulcer-related amputation will have a further amputation within the first year; after five years, that percentage increases to 50% [15]. For this group, diabetes education, tight glycemic control, daily foot care, and regular check-ups with a podiatrist are crucial.

6. CONCLUSION

Diabetic foot ulcers are complex complications that require early recognition, comprehensive assessment, and coordinated management. Prevention begins with identifying patients at increased risk, particularly those with loss of protective sensation, peripheral arterial disease, foot deformity, or a history of ulceration. Regular foot examination, daily self-inspection, appropriate footwear, pressure reduction and off-loading, professional foot care, and patient education are essential components of prevention. When an ulcer develops, successful management requires more than treating the wound itself. Appropriate debridement, infection assessment and treatment, vascular evaluation, effective offloading, and management of underlying metabolic and mechanical factors are critical to healing. Advanced therapies, including negative pressure wound therapy, hyperbaric oxygen therapy, and selected cellular or tissue-based products, may have a role in carefully selected wounds that do not respond adequately to standard care. Finally, healing should not be considered the end of treatment. A history of diabetic foot ulceration places the patient at continuing high risk for recurrence, requiring lifelong preventive foot care, regular professional assessment, and patient engagement. Through systematic assessment and timely intervention, healthcare professionals can help reduce ulcer-related complications, preserve limb function, and improve outcomes for people living with diabetes.

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Evidence-Based Practice Recommendations Citations

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