Clinical Review

Managing complications of the diabetic foot

BMJ 2009; 339 doi: (Published 02 December 2009) Cite this as: BMJ 2009;339:b4905
  1. Kelly Cheer, specialist trainee 4 in diabetes and endocrinology1,
  2. Cliff Shearman, professor of vascular surgery2,
  3. Edward B Jude, consultant diabetologist and endocrinologist and honorary senior lecturer1
  1. 1Diabetes Centre, Tameside Hospital NHS Foundation Trust, Ashton under Lyne, Lancashire, OL6 9RW
  2. 2University of Southampton, Southampton General Hospital, Southampton SO16 6YD
  1. Correspondence to: E B Jude Edward.jude{at}

    Summary points

    • Foot problems occur in around 5% of patients with diabetes each year and cause considerable morbidity and mortality

    • Problems are caused by peripheral neuropathy or peripheral arterial disease (or both)

    • Patients with diabetes should be assessed at least once a year for foot pulses, foot sensation, and risk of ulceration

    • Up to a third of patients with foot ulcers have osteomyelitis, which can be difficult to diagnose

    • Charcot’s neuroarthropathy must be considered in patients presenting with a unilateral hot or swollen foot

    • Advice and education on foot care are essential for patients with diabetes

    Fifteen per cent of patients with diabetes will develop a foot ulcer in their lifetime. Foot complications (box 1) account for more hospital admissions than any other complication of diabetes, with considerable morbidity and mortality.1 People with diabetes are eight to 24 times more likely than those without diabetes to have a lower limb amputated.2 Around 85% of these amputations could be avoided by early detection of foot complications, timely intervention, involvement of a diabetic foot care team, good diabetes control, and patient education.3 4 Although we review the various complications separately, patients often have multiple problems.

    Sources and selection criteria

    We searched Medline and PubMed from 1995 to 2009, focusing on evidence based publications on the diabetic foot and randomised trials for treatment of diabetic foot complications. We supplement these sources with our own knowledge of the literature and selected reviews.

    Box 1 Foot complications in diabetes5

    • Peripheral neuropathy (20-40% of patients with diabetes)

    • Peripheral vascular disease (20-40% of patients with diabetes)

    • Foot ulceration (5% of patients with diabetes a year)

    • Foot infection and osteomyelitis (22-66% of all foot ulcers)

    • Amputation (0.5% of patients with diabetes a year)

    • Charcot’s neuroarthropathy (0.1-0.4% of patients with diabetes a year)

    In 1989 the St Vincent Declaration set out the aim of reducing lower limb amputations …

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