Diabetic foot disease is a serious complication affecting individuals with diabetes, primarily resulting from a combination of peripheral neuropathy and peripheral arterial disease (PAD) (Ghirardini and Martini, 2024). These conditions lead to a loss of protective sensation, reduced blood supply, and the subsequent risk of foot ulcers, infections, and gangrene (Parise et al, 2024). Diabetic foot disease often requires hospitalisation due to its potential to cause significant morbidity and, in extreme cases, lower limb amputations (Lazzarini et al, 2024). Diabetic foot complications are a significant concern globally, with a substantial burden on healthcare systems. Approximately 19% to 34% of people with diabetes will develop a diabetic foot ulcer (DFU) in their lifetime (Centers for Disease Control and Prevention, 2024). The prevalence of these complications increases with age and the duration of diabetes, making regular foot assessments crucial (National Institute for Health and Care Excellence (NICE), 2022). In the USA, around 160 000 people with diabetes undergo amputations each year, with up to 80% being non-traumatic lower limb amputations (American Diabetes Association (ADA), 2025). According to the ADA (2025), a limb is amputated every 3 minutes and 30 seconds in the USA due to diabetes, many cases of which are preventable. Research for Public Health England (PHE) reported 27 465 amputations between 2015 and 2018, compared with 24 181 cases between 2012 and 2015 – a rise of 14% (Kerr et al, 2019). In England, 7957 major diabetic lower-limb amputations were reported between 2017/18 and 2019/20, many of which were attributable to poor diabetic control (NHS Resolution, 2022). Approximately every 30 seconds, a lower limb is amputated globally due to diabetes-related complications (Haider, 2023).
About half of all people with diabetes have some form of nerve damage (neuropathy), significantly increasing the risk of developing foot ulcers (ADA, 2025). Diabetic foot ulcers are a common and highly morbid consequence of poorly managed diabetes, leading to severe complications if not treated promptly (Mekonnen, 2024). A systematic review of studies comparing PAD in people with and without diabetes reported that PAD prevalence ranged between 20% and 50% in those with diabetes, compared with between 10% and 26% in those without diabetes (Stoberock et al, 2021).
In the UK, diabetes is one of the most common chronic diseases, with its prevalence increasing annually (Diabetes UK, 2024); nearly 2.9 million people were diagnosed with diabetes in 2013, and this number has continued to grow (NICE, 2016). In the USA, the direct medical costs attributed to diabetes increased by 7% between 2017 and 2022, indicating a rising financial burden on healthcare systems (ADA, 2023). The risk of DFU complications increases with patient age and the duration of diabetes, making regular foot assessments and appropriate management crucial for prevention and early intervention. These statistics highlight the critical need for effective prevention, early diagnosis, and management strategies to mitigate the impact of diabetic foot complications.
This review aims to provide a detailed assessment tool for the inpatient management of diabetic foot disease. It emphasises the importance of early detection, multidisciplinary management, and adherence to clinical guidelines to prevent severe complications. The article highlights key risk factors, diagnostic tools and treatment strategies, providing a comprehensive clinical pathway for health professionals. It builds on existing literature by integrating the latest evidence, including the latest International Working Group on the Diabetic Foot (IWGDF) guidelines (Senneville et al, 2023). The IWGDF guidelines emphasise a practical approach, detailed referral pathways and multidisciplinary care strategies, offering updated tools and insights to improve clinical outcomes and address often overlooked aspects within inpatient services.
Pathophysiology of diabetic foot disease
Peripheral neuropathy
Peripheral neuropathy affects around 50% of people with diabetes, causing sensory, motor and autonomic dysfunction (Zhu et al, 2024a). Sensory neuropathy leads to a loss of pain sensation, so patients may not feel minor injuries or pressure ulcers forming, allowing them to develop unnoticed (Kraus, 2024). Motor neuropathy can result in muscle imbalances, leading to foot deformities such as hammer toes or claw toes, which further increase the risk of ulceration (Wang et al, 2022). Autonomic neuropathy reduces sweat production, leading to dry skin and the potential for cracks and fissures to form, which can become entry points for infection (Balasubramanian, 2022).
Peripheral arterial disease
PAD is common in people with diabetes, with up to 50% of patients with diabetic foot ulcers exhibiting signs of ischaemia (Brownrigg et al, 2013). Reduced blood flow compromises the skin's ability to heal after injury, and the presence of ischaemia significantly increases the risk of infection.
The dual presence of neuropathy and ischaemia, referred to as neuroischaemic foot, is a particularly dangerous combination, leading to a higher risk of ulceration and gangrene (Hinchliffe et al, 2014). The neuroischaemic foot is characterised by a cool, pulseless presentation with thin, shiny and hairless skin. In addition, subcutaneous tissue atrophy is common, and due to underlying neuropathy, symptoms such as intermittent claudication and rest pain may be absent (Packer et al, 2018).
Immunosuppression in diabetes
Diabetes compromises immune function, impairing both the innate and adaptive immune responses (Berbudi et al, 2020). Hyperglycaemia affects the ability of neutrophils to perform phagocytosis and reduces the production of cytokines, leading to an increased risk of infection (Jafar et al, 2016). Furthermore, poor glycaemic control has been associated with prolonged wound healing, exacerbating the risk of infection and deep-tissue involvement such as osteomyelitis (Matheson et al, 2021).
Risk factors for diabetic foot complications
Intrinsic factors
Intrinsic factors leading to complications include:
Extrinsic factors
The following are extrinsic factors affecting diabetic foot complications:
Diabetic foot assessment
Initial examination
The initial phase of diabetic foot assessment includes a comprehensive visual and tactile examination. Nurses should remove the patient's shoes, socks, and any bandages or dressings to fully inspect both feet (Nather, 2023). Look for signs of:
Vascular assessment
The vascular examination should include palpation of the dorsalis pedis and posterior tibial pulses. The absence of palpable pulses indicates ischaemia and further vascular studies may be required (NHS Borders, 2024). Doppler ultrasound or ankle-brachial index (ABI) testing can help quantify the degree of ischaemia (NICE, 2019).
Neurological examination
The Ipswich Touch Test (IpTT) is a simple, non-invasive screening tool designed to detect peripheral neuropathy (Rayman et al, 2011). The test involves gently touching the tips of the first, third, and fifth toes bilaterally using the fingertip. Patients are instructed to keep their eyes closed and immediately signal vocally when they feel the touch (Senthilkumar et al, 2023). The scoring system classifies 0/6 as a poor score, 6/6 as a good score, and <4/6 as indicative of neuropathy. When compared with the 10 g monofilament test, the most widely used screening instrument for detecting the loss of protective sensation in diabetic patients, the IpTT has demonstrated substantial reliability (kappa=0.68) and strong diagnostic performance, with a sensitivity of 76% and a specificity of 90% (Rayman et al, 2011). The 10 g monofilament test is essential for evaluating the loss of protective sensation (Hazari et al, 2024). The monofilament is applied to specific pressure points on the plantar surface of the foot to identify patients at high risk of ulceration or injury.
Further neurological assessment tests
Other neurological assessment tests include:
Integrating these tests into clinical practice facilitates a thorough evaluation, ensuring a comprehensive assessment of neuropathy. Recent studies have highlighted the effectiveness of the IpTT in screening for diabetic peripheral neuropathy. A recent systematic review and meta-analysis by Zhao et al (2021) found that the IpTT has a pooled sensitivity of 0.77 and a specificity of 0.96 when compared to the 10 g monofilament test, concluding that it is a reliable tool. This implies reference to remote areas and primary medical institutions, which could include GP settings, although not mentioned explicitly. Another systematic review reported that the sensitivity of the IpTT ranges from 51% to 83.3% and the specificity from 96.4% to 98% when compared to the 10 g monofilament test (Hu et al, 2021). When compared with the vibration perception test, the sensitivity ranges from 76% to 100% and the specificity from 90% to 96.6%. These findings highlight the high specificity of the IpTT, making it a valuable tool for identifying loss of protective sensation in patients with diabetes, particularly in settings where more sophisticated tools are not accessible.
Table 1 demonstrates the diabetic foot disease management approach, drawing on various literature and guidelines. It outlines interventions focused on a patient's clinical findings. This approach facilitates the early detection and effective management of diabetic foot complications.
| Step | Action |
|---|---|
| Initial assessment | Assess all patients with diabetes for an active foot ulcer, severe infection (eg deep abscess, systemic illness, spreading cellulitis), acute critical limb ischaemia, necrosis/gangrene, or acute Charcot foot (red, hot, swollen foot, with or without pain) |
| Pulse check | Are pulses present? |
| Active foot ulcer |
|
| Acute Charcot foot | Perform a baseline weight-bearing X-ray. If inconclusive, order an MRI. If Charcot foot is suspected: immediate immobilisation is required, provide crutches if needed, provide basic non-weight-bearing advice, and complete the podiatry point-of-contact form |
| No clinical features (differential diagnoses) | If no signs of infection, Charcot foot or ischaemia are present, consider differential diagnoses: deep vein thrombosis, acute gout, inflammatory arthritis, or sprain/fracture. Refer the patient to the relevant specialist team |
| Acute critical limb ischaemia | Signs include discolouration of toes/foot (pale, dusky, or black), pain at rest (often worse at night), acute pain, pallor, pulselessness, cold sensation, paraesthesia or paralysis |
| Necrosis/gangrene | Signs include visible necrosis or gangrene, foul odour or tissue breakdown |
Assessing the severity of the infection
Foot infections are classified based on severity:
Classifying a diabetic foot ulcer
Accurate classification of the DFU is essential for effective management and preventing complications. As outlined in Table 2, based on IWGDF guidelines (Monteiro-Soares et al, 2023), the Wound, Ischaemia, and Foot infection (WIfI) classification system provides a structured framework to assess wound severity, ischaemia and infection. This system categorises ulcers from minor tissue loss (grade 0) to extensive tissue loss (grade 3), helping to stratify healing potential and amputation risk. This guides clinical decisions on possible interventions such as revascularisation and debridement, while improving multidisciplinary communication. By ensuring patients are managed under the correct specialty team and following appropriate diagnostic pathways (Wang et al, 2022), the WIfI system enables evidence-based care, promotes limb preservation and ensures timely intervention for better outcomes.
| Grade | Diabetic foot ulcer | Gangrene |
|---|---|---|
| 0 | No ulcer | No gangrene |
| 1 | Small, shallow ulcer(s) on distal leg or foot; no exposed bone, unless limited to distal phalanx |
No gangrene |
| 2 | Deeper ulcer with exposed bone, joint or tendon; generally not involving the heel; shallow heel ulcer without calcaneal involvement |
Gangrenous changes are limited to digits |
| 3 | Extensive, deep ulcer involving forefoot and/or midfoot; deep, full-thickness heel ulcer ± calcaneal involvement |
Extensive gangrene involving forefoot and/or midfoot; full-thickness heel necrosis ± calcaneal involvement |
Diagnostic tools and investigations
Laboratory investigations
The following laboratory investigations are recommended:
Imaging techniques
The following imaging techniques may be used:
Management of diabetic foot problems
Initial care guidelines
Health professionals should follow their trust guidelines for all inpatients with diabetes and suspected foot problems. Such patients should receive an initial assessment within 24 hours. If an infection is present, empirical antibiotic therapy should begin based on clinical guidelines while awaiting culture results. Blood glucose levels should be optimised to improve wound healing and reduce infection risk (Joint Formulary Committee, 2024).
Referral to the diabetic foot team
Inpatients with foot ulcers, infection or ischaemia should be referred to the hospital diabetic foot team within 24 hours (NICE, 2019). The multidisciplinary team, comprising podiatrists, diabetologists and vascular surgeons, will work collaboratively to manage the patient's condition. Timely referral is essential in preventing progression to severe infection or amputation.
Antibiotic therapy
Antibiotic selection is guided by the severity of the infection (Joint Formulary Committee, 2024):
Treatment should be adjusted based on culture results and the patient's clinical response.
Preventive strategies for hospital-acquired diabetic foot disease
Daily foot inspections
In hospital, daily inspection of the feet, including all pressure areas, is essential for identifying early signs of ulceration (Reardon et al, 2020). Regular documentation of the foot condition in the patient's clinical notes is recommended. This allows health professionals to track changes and intervene early if problems arise (Veves et al, 2024).
Pressure relief strategies
Inpatients at risk of developing foot ulcers should receive appropriate pressure-relief strategies (Bus et al, 2020). Pressure-relieving devices, such as foam mattresses or heel protectors, reduce pressure on vulnerable areas such as the heels (Greenwood et al, 2022). Mobility should be encouraged where appropriate to reduce the risk of pressure ulcers forming.
Long-term management and discharge planning
Role of blood glucose control
Optimised glycaemic control is critical in preventing infection and promoting wound healing (Rastogi et al, 2022). Diabetes specialist nurses should assess patients regularly to adjust insulin or oral hypoglycaemic agents as needed. Maintaining glucose within target ranges has been shown to improve outcomes in patients with diabetic foot disease (Hinchliffe et al, 2020).
Protective footwear and orthotic devices
Patients with foot deformities or healed ulcers should be provided with custom footwear to prevent further complications (Armstrong et al, 2023). These devices provide pressure relief in high-pressure areas, including the heel – which is maintained in a pressure-relieved state – thereby reducing the risk of recurrence.
Vascular management
Effective management of diabetic foot disease requires a holistic approach that goes beyond infection control to include vascular assessment, debridement and pressure relief. Vascular management is critical, with initial assessments focusing on arterial pulses and further investigations, such as ABI and Doppler ultrasound, guiding referrals to vascular specialists for interventions such as revascularisation or bypass surgery (Fitridge et al, 2023). Debridement plays a vital role in wound care by removing necrotic tissue, reducing bacterial load and promoting healing; this can be performed using sharp, enzymatic or autolytic techniques, depending on the clinical context. Pressure relief is equally important in redistributing pressure to prevent and treat foot ulcers, with options including total contact casts, removable cast walkers and custom orthotics (Bus et al, 2020).
In Table 1, clear referral pathways have been outlined to guide timely interventions for severe infections, ischaemia and complications such as Charcot foot. A multidisciplinary approach that integrates infection management, vascular care, pressure relief and regular debridement improves outcomes and reduces the risk of limb loss in diabetic foot disease.
Outpatient follow-up
Referral to specialist diabetic foot clinics for long-term management post-discharge
After discharge, patients with diabetic foot disease require structured follow-up in specialist diabetic foot clinics to monitor their healing and prevent the recurrence of complications (Boulton et al, 2018). These clinics are staffed with multidisciplinary teams, including diabetes clinical nurse specialists, podiatrists, diabetologists and vascular surgeons, who can provide comprehensive care. Early referral to these clinics is essential, as studies have shown that regular monitoring and prompt intervention can reduce the incidence of re-ulceration and improve healing outcomes (Vas and Chockalingam, 2023).
Regular follow-ups for high-risk patients to monitor healing and prevent complications
High-risk patients with a history of ulcers, amputations or severe neuropathy should be scheduled for frequent follow-up visits (Rubio et al, 2020). The frequency of these visits will depend on the severity of the patient's condition, but NICE guidelines (2016) typically recommends weekly or bi-weekly assessments for patients with active foot ulcers. During these visits, clinicians will assess the healing process, check for signs of infection, and evaluate the effectiveness of pressure-relieving devices or footwear. Continuous monitoring is critical to prevent complications such as infection, delayed healing, and, ultimately, the need for surgical intervention (Bellomo et al, 2022).
Challenges in inpatient diabetic foot care
Delays in foot assessment and barriers to timely intervention
One of the principal challenges in managing diabetic foot disease in inpatients is minimising the delay in initial foot assessment (Morris et al, 2023). Foot checks are often deprioritised, especially in patients admitted for other conditions, resulting in missed early signs of ulceration or infection. Furthermore, health professionals may lack the necessary training to recognise the signs of diabetic foot complications, leading to delayed referral to specialist teams. Timely intervention is critical because even short delays in treating diabetic foot infections or ischaemia can lead to rapid disease progression, significantly increasing the risk of amputation.
A systematic review by Nickinson et al (2020) found that the median time from symptom onset to specialist healthcare assessment for patients with chronic limb-threatening ischaemia and foot ulceration ranged from 15 to 126 days. Once assessed, the median time to treatment varied between 1 and 91 days, highlighting the importance of prompt diagnosis and timely management to prevent severe outcomes.
Delay in referral to specialist care
Delays in referring patients with diabetic foot problems to specialist care remain a significant challenge, as identified by health professionals in a study by Pankhurst and Edmonds (2018). When 425 health professionals were asked to identify barriers to effective foot care for people with diabetes, they highlighted poor recognition and diagnosis of foot complications, as well as a lack of awareness regarding the necessity of timely referrals among both patients and health professionals. In addition, difficulties in navigating referral pathways and accessing specialist foot services were frequently noted. Limited access to multidisciplinary care, alongside resource shortages and inadequate education for both patients and health professionals, were also cited as contributing to delays.
The study also revealed that funding constraints, the centralisation of vascular services, and insufficient staffing exacerbate delays. A critical issue that has been highlighted is the shortage of health professionals working in primary care. This reduces the capacity to assess diabetic foot complications early, further delaying specialist intervention and increasing the risk of adverse outcomes.
Impact of limited resources or staffing on diabetic foot care
Limited staffing, particularly the shortage of podiatrists, presents a significant barrier to providing adequate diabetic foot care. McIntosh (2017) estimated a national shortage of 7000 podiatrists, which has hampered access to effective multidisciplinary foot team (MDFT) services. Furthermore, Getting It Right First Time (GIRFT) reported in 2020 that many hospitals still lack fully established MDFTs (Rayman et al, 2020). This staffing shortfall means that hospitals may struggle to conduct regular foot inspections or deliver specialist care, leading to delays in diagnosis and treatment. Additionally, overburdened radiology departments may exacerbate these delays by limiting access to essential diagnostic tools such as MRI or Doppler studies. These constraints can result in suboptimal care and poorer patient outcomes, making resource allocation and staff training critical to improving diabetic foot management.
The impact of socioeconomic factors on diabetic foot disease progression and management
Socioeconomic factors significantly exacerbate the pathophysiology of diabetic foot disease by influencing lifestyle behaviours and access to healthcare resources. Patients from lower socioeconomic backgrounds often experience higher rates of smoking, excessive alcohol consumption, and obesity, all of which are established risk factors for diabetic foot disease. Smoking impairs microcirculation and oxygen delivery to tissues, thereby hindering wound-healing processes (Gethin et al, 2022). Obesity contributes to increased plantar pressure, leading to a higher incidence of foot ulcers (Khalaf et al, 2022). Moreover, limited health literacy in socioeconomically disadvantaged populations can result in delayed recognition of diabetic foot disease symptoms, postponing timely medical intervention. Barriers to healthcare access, such as financial constraints and inadequate transportation, further impede the management of diabetic foot disease, culminating in poorer clinical outcomes (Liu et al, 2021). Addressing these socioeconomic disparities is crucial for effective prevention and treatment strategies in this condition.
Importance of a multidisciplinary team approach
Role of different health professionals in managing diabetic foot problems
Managing diabetic foot disease requires a multidisciplinary team approach, as it involves complex interactions between neuropathy, ischaemia and infection (NICE, 2016). The team should include a diabetologist to manage glucose control, a podiatrist for wound care and pressure-relief strategies, a vascular surgeon to address ischaemia, and an infectious disease specialist or microbiologist to guide antibiotic therapy (Veves et al, 2024). Nurses, particularly diabetes specialist nurses and tissue viability nurses, play a crucial role in monitoring the patient's condition and implementing treatment plans (Zhu et al, 2024b). Pharmacists also contribute by ensuring appropriate and safe antibiotic use based on culture results and by assisting in optimising glycaemic control (Maity et al, 2024).
Effective patient education and self-management are key to preventing the recurrence of diabetic foot problems (Pouwer et al, 2024). Teaching patients about the importance of daily foot inspections, appropriate footwear and maintaining optimal blood glucose levels can significantly reduce the risk of foot ulcers and infections (Untari et al, 2024). There is a growing potential for incorporating digital tools, such as mobile phone apps, into patient education and self-care routines (Sharma et al, 2024). These tools can provide reminders for foot inspections, monitor blood glucose levels, and offer guidance on proper foot-care practices. As patient engagement and self-management improve, so too will the overall outcomes for individuals at risk of diabetic foot disease.
Benefits of an integrated care pathway to reduce hospital-acquired infections and amputations
An integrated care pathway brings together the expertise of various health professionals, ensuring that diabetic foot patients receive comprehensive care. Studies have demonstrated that multidisciplinary care significantly reduces the rate of hospital-acquired infections, improves ulcer healing times and lowers amputation rates (Musuuza et al, 2020; Morris et al, 2023). Collaboration between teams allows for the rapid identification of foot problems, immediate intervention and effective co-ordination of treatment plans, which are all essential for improving patient outcomes. Regular interdisciplinary meetings and diabetic foot rounds help ensure that all aspects of the patient's care are addressed, leading to more efficient and effective diabetic ulcer management.
Future directions
Advances in imaging, diagnostics and telemedicine for diabetic foot care
Recent advances in imaging, such as high-resolution MRI and advanced Doppler techniques, have improved the ability to diagnose complications such as osteomyelitis and ischaemia at earlier stages. Additionally, developments in non-invasive diagnostic techniques, such as infrared thermography, show promise in detecting inflammation and early signs of infection before they manifest clinically. Telemedicine has also emerged as a valuable tool for managing diabetic foot disease, particularly for follow-up care. Remote consultations and digital wound monitoring allow clinicians to track the progress of healing, provide timely advice and to intervene when necessary, all while reducing the burden on healthcare facilities.
Conclusion
Diabetic foot disease remains a significant challenge for both patients and health professionals due to its complex pathophysiology and potential for severe complications. Early assessment and intervention are critical in managing this condition, and the importance of routine foot inspections, proper diagnosis and timely treatment cannot be overstated. A multidisciplinary approach, involving diabetologists, podiatrists, surgeons, diabetes specialist nurses and ward nurses, is essential for ensuring comprehensive care and reducing the incidence of complications such as infection and amputation.
Looking ahead, advances in imaging, diagnostics and telemedicine offer new opportunities for improving diabetic foot care, while patient education and self-management remain the cornerstones of long-term prevention. Health professionals should remain vigilant in recognising the signs of diabetic foot disease and act promptly to prevent adverse outcomes. With continued improvements in care pathways, resource allocation and patient education, it is possible to reduce the burden of diabetic foot disease and enhance the quality of life for individuals with diabetes.