Among persons diagnosed as having diabetes mellitus, the prevalence of foot ulcers
is 4% to 10%, the annual population-based incidence is 1.0% to 4.1%, and the lifetime
incidence may be as high as 25%. These ulcers frequently become infected, cause great
morbidity, engender considerable financial costs, and are the usual first step to
lower extremity amputation.
To systematically review the evidence on the efficacy of methods advocated for preventing
diabetic foot ulcers in the primary care setting.
The EBSCO, MEDLINE, and the National Guideline Clearinghouse databases were searched
for articles published between January 1980 and April 2004 using database-specific
keywords. Bibliographies of retrieved articles were also searched, along with the
Cochrane Library and relevant Web sites. We reviewed the retrieved literature for
pertinent information, paying particular attention to prospective cohort studies and
randomized clinical trials.
Prevention of diabetic foot ulcers begins with screening for loss of protective sensation,
which is best accomplished in the primary care setting with a brief history and the
Semmes-Weinstein monofilament. Specialist clinics may quantify neuropathy with biothesiometry,
measure plantar foot pressure, and assess lower extremity vascular status with Doppler
ultrasound and ankle-brachial blood pressure indices. These measurements, in conjunction
with other findings from the history and physical examination, enable clinicians to
stratify patients based on risk and to determine the type of intervention. Educating
patients about proper foot care and periodic foot examinations are effective interventions
to prevent ulceration. Other possibly effective clinical interventions include optimizing
glycemic control, smoking cessation, intensive podiatric care, debridement of calluses,
and certain types of prophylactic foot surgery. The value of various types of prescription
footwear for ulcer prevention is not clear.
Substantial evidence supports screening all patients with diabetes to identify those
at risk for foot ulceration. These patients might benefit from certain prophylactic
interventions, including patient education, prescription footwear, intensive podiatric
care, and evaluation for surgical interventions.