The tip of the iceberg: an overview of diabetic foot disease

Wilson, P. & Patton, D. | 2021 | The tip of the iceberg: an overview of diabetic foot disease |


Diabetic foot disease is the leading cause of lower-extremity amputation globally and imposes a significant burden for healthcare services and patients alike. The main pathology is ulceration, due to neuropathy or peripheral arterial disease. The most frequent sign is ulceration on the foot. Ulceration needs to be referred to the multidisciplinary diabetic foot team promptly for a comprehensive management plan to be developed. Delay in referral is associated with poor outcomes. Management of diabetic foot ulceration is multifaceted, including offloading, revascularisation, infection control, debridement, glycaemic control and wound care. Management plans need to be patient focused and developed collaboratively across primary and secondary care settings.

This article is available to Rotherham NHS staff and can be requested from the Library

NIHR: People with diabetes with a low risk of developing foot ulcers can be screened less often

NIHR | January 2021 | People with diabetes with a low risk of developing foot ulcers can be screened less often

Current NICE guidance recommends that people with diabetes have their feet screened annually to identify those most at risk of developing foot ulcers.  Now a new NIHR- funded study suggests that annual foot checks could be reduced. It found that people at low risk of developing ulcers do not need yearly reviews, as 1 in 20 patients at low risk of a foot ulcer progressed to medium risk level over a two year period.

The researchers analysed the data of over 10 000 patients in Scotland diagnosed with diabetes, who attended their first screening session in the period from 2009 to 2017. From this they identified each individual’s risk of foot ulceration according to standard risk factors of insensitivity, previous ulcers, and whether pulses in the foot could be felt. They looked at the change over time – from low to moderate risk. They cross-referenced this information with data on ulceration, amputation and death.

The results showed:

  • People with diabetes changed from low to moderate risk slowly
  • Around one in ten changed from low to moderate risk after five years (9.9 %) and eight years (11.3%)
  • Most changes in risk status (94%) were down to nerve damage in the feet (peripheral neuropathy)
  • One in 250 (0.4%) in the low-risk group developed ulcers after two-years; one in a thousand (0.1%) had an amputation (Source: NIHR).

Read the full NIHR Alert

Primary paper is available from Diabetic Medicine

Bespoke 3D insoles could significantly improve diabetes foot health| July 2020 | Bespoke 3D insoles could significantly improve diabetes foot health


Newly developed 3D printed insoles could be the answer to preventing foot ulcers among people with diabetes, researchers have said.


A team from Staffordshire University has carried out a study on the product and found tailoring the stiffness of the cushioning insole, could significantly improve the foot health of the wearer by reducing pressure on the feet.


They found much of the insole’s success was linked to tailoring it around the person’s weight.


Lead study author Dr Chatzistergos, Associate Professor at the university’s Centre for Biomechanics and Rehabilitation Technologies (CBRT), said: “The optimum stiffness is clearly related to the patient’s body mass index (BMI). This study adds to our earlier findings and concludes that stiffer materials are needed for people with a higher BMI.”


These findings could be hugely significant as it is thought that around 2-2.5 per cent of the diabetes population has a foot ulcer in any given week. If left untreated they can sometimes lead to limb amputation.


The recently published research is thought to be the first trial which has looked at optimising cushioning for diabetic footwear as part of clinical practice.


A total of 15 people with diabetic foot disease were recruited for the study. They were asked to walk around in the adapted footwear, fitted with the bespoke 3D printed insoles.


They were specifically customised to fit across the surface of the foot bed and the material’s stiffness varied from very soft to very stiff.


Because of the positive study outcomes, the team are now focussing their efforts on trying to find a way to enable healthcare professionals to identify the individual cushioning needs of each person with diabetes thats they see.


Professor Nachi Chockalingam, Director of CBRT and co-inventor of the technology, said: “With numerous patients losing their limbs to diabetic foot disease, our research will help clinicians effectively manage this disease.” (Source: Staffordshire University)


Staffordshire University 3D printed insoles offers new hope for patients with diabetes


The research findings have been published in the Gait and Posture journal.




Correct selection of cushioning stiffness significantly improves pressure reduction.


Patient specific selection can maximise pressure reduction in diabetic feet.


Patient specific optimum stiffness was correlated to the participants’ body weight.


Stiffer cushioning materials were needed for higher magnitudes of loading.


Further research is needed for clinically applicable optimisation of cushioning.


The full article can be requested from the Library & Knowledge Service

National diabetes audits

The Healthcare Quality Improvement Partnership has published the results of the following audits relating to diabetes:

Image source:

  • National Paediatric Diabetes Audit: annual report 2017-18: care processes and outcomes – provides an analysis of data for children and young people with diabetes including information on prevalence of diabetes, diabetes-related outcomes and complications, compliance with health care checks and recommendations for improvements in care
  • National Diabetes Inpatient Audit – measures the quality of diabetes care provided to people with diabetes while they are admitted to hospital.  The results are presented in two reports covering the hospital characteristics survey and serious inpatient harms

Additional links: NHS Digital – National Diabetes Inpatient Audit (NaDIA) – 2018 | NHS Digital National Diabetes Inpatient Audit – Harms, 2018

Additional link: NHS Digital – National Diabetes Foot Care Audit, 2014-2018

Improving foot care outcomes for people with diabetes in Wessex

NICE | April 2019|Improving foot care outcomes for people with diabetes in Wessex

NICE’s shared learning database has published Improving foot care outcomes for people with diabetes in Wessex

Reducing the number of amputations among people living with diabetes in Wessex has been a key aim of the Wessex Cardiovascular Clinical Network (CVD CN). A structured series of projects have been undertaken since 2015, which has included significant engagement with a wide range of clinicians, operational managers, commissioners and patients.


The Wessex Foot Care standards were jointly developed and agreed by local stakeholders including clinicians and commissioners, with the Specialist Clinical Network facilitating the process. They set out the care that people with diabetes should expect based on NICE NG19, 2015 and that commissioners and providers should strive to provide, and were also published in 2015. The implementation of the standards across Wessex aims to reduce variation in care and improve outcomes for people living with diabetes related foot complications. A peer review of all diabetes foot care services across Wessex has recently been undertaken to support regional service improvements and included patient interviews.

Full details from NICE 

Diabetes foot ulcer service digital imaging in the community


Improving Diabetic Foot Care: A Guide for Commissioners

The College of Podiatry in collaboration with Health Education England and Insight Health Economics have produced a toolkit for commissioners in England to enable Diabetic Foot Care services to provided more effectively.


The College are calling on healthcare commissioners to prioritise diabetic foot care and end avoidable amputations that can have a devastating impact on the lives of patients and their families and cost the NHS millions.

Complications from diabetic foot disease are costing the NHS in England more than a billion pounds a year. Today, and every day, 23 people with diabetes in England will have a toe, foot or leg amputated. A third of these are major amputations, meaning that the patient loses their whole foot above the ankle or even more of their leg. Many of these amputations are preceded by diabetes related foot ulcers, caused by a combination of impaired circulation and nerve damage – common problems experienced by people with diabetes.

Experts believe that by improving the way diabetic foot health is commissioned and delivered, around half of these life-shattering surgeries could be avoided.

Full detail: Improving Diabetic Foot Care: A Guide for Commissioners