DM Full Guideline (2010) - VA/DoD Clinical Practice Guidelines Home

Version 4.0
VA/DoD Clinical Practice Guideline
for the Management of Diabetes Mellitus
resolved, the patient should be referred to a foot care specialist for intensive secondary prevention (Conte et al.,
1995; Currie et al., 1995).
Initial therapy could include antibiotics, wound cleansing, tetanus prophylaxis (if indicated), and/or same-day
referral to a foot care specialist.
Patients with diabetes, especially neuropathic patients, often present late for treatment with mixed aerobic and
anaerobic infections that require prompt referral and evaluation by a qualified provider who is experienced in the
management of this condition (Lavery et al., 1995).
EVIDENCE
Recommendation Sources LE QE SR
1 Referral for limb-threatening
conditions.
2 Referral to a vascular specialist for
symptoms that limit lifestyle.
Working Group Consensus III Poor I
Conte et al., 1995
Currie et al., 1995
Lavery et al., 1995
LE-Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A).
E. Is Patient at High-Risk for a Foot Problem?
OBJECTIVE
Identify the patient at high-risk for LE foot ulcers and amputations.
RECOMMENDATIONS
1. Patients without limb-threatening conditions should be evaluated for their level of risk for LE foot ulcers
and amputations.
2. The existence of one of the following characteristics is sufficient to define the patient as high-risk for foot
problem.
• Lack of sensation to Semmes-Weinstein 5.07 monofilament at one or more noncallused plantar sites
• Evidence of LE arterial disease (absence of both dorsalis pedis and tibialis posterior pulses, dependent
rubor with pallor on elevation, history of rest pain or claudication, and prior history of LE bypass
surgery)
• Foot deformities (specifically hammer toes, claw toe, Charcot's arthropathy, bunions, and metatarsal
head deformities)
• History of foot ulcer or non-traumatic LEA at any level.
3. The patient at high-risk should be referred to a foot care specialist for a more comprehensive evaluation and
intensive treatment plan including patient education concerning foot care practices, hygiene, and footwear.
A foot care specialist is defined as a podiatrist, vascular surgeon, orthopedic surgeon, or other healthcare provider
with demonstrated training, competence, and licensure in foot care.
III
II
III
Poor
I
Module F – Foot Care Page 100