A Health Care Provider’s Guide to Preventing Diabetes Foot Problems pptx

F e e t Ca n La s t
a Li fet i m e
A Health Care Provider’s Guide to
Preventing Diabetes Foot Problems
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“ eet Can Last A Lifetime” was produced by the National Diabetes Education Program (NDEP). The NDEP
is a partnership among the National Institutes of Health, the Centers for Disease Control and Prevention,
and over 200 organizations. Partners who contributed to the development of this national effort include:
American Association of Diabetes Educators
American Diabetes Association
American Orthopaedic Foot & Ankle Society
American Podiatric Medical Association
Centers for Disease Control and Prevention
Health Care Financing Administration
Health Resources and Services Administration
Indian Health Service
Juvenile Diabetes Foundation International
New Mexico Medical Review Association
National Institute of Diabetes and Digestive and Kidney Diseases,
National Institutes of Health
Pedorthic Footwear Association
Veterans Health Administration
A joint program of the National Institutes of Health
and the Centers for Disease Control and Prevention
F
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F e e t Ca n La s t
a Li fet i m e
A Health Care Provider’s Guide to
Preventing Diabetes Foot Problems
2404pFeetCanLastALifetime 3/7/01 6:38 PM Page 3

A c k n o w l e d g m e n t s
M
any people have contributed to the development of this kit. Almost 20,000 copies of the kit have
been ordered since its first printing in 1998. Before reprinting this second edition, the original
materials were reviewed, revised and updated. Re p re s e n t a t i ves from the “Feet Can Last a Lifetime”
p a rtner organizations offered substantive comments on the content and presentation of the material for this
second edition. They are listed below.
American Association of Diabetes Educators
Council on Foot Care, American Diabetes Association
Council on Foot Care, American Diabetes Association
American Diabetes Association
Clinical Affairs, American Diabetes Association
American Orthopaedic Foot & Ankle Society
American Podiatric Medical Association
Lower Extremity Amputation Prevention Program, Bureau of
Primary Health Care, HRSA
Centers for Disease Control and Prevention,
Division of Diabetes Translation
Centers for Disease Control and Prevention,
Division of Diabetes Translation
Food and Drug Administration
Health Care Financing Administration
Health Care Financing Administration
New Mexico Medical Review Association
New Mexico Medical Review Association
Bemidji Area Indian Health Service, PHS Indian Hospital,
Cass Lake, Minnesota
Indian Health Service Diabetes Program
Juvenile Diabetes Foundation International
National Diabetes Education Program, NIDDK,

National Institutes of Health
National Diabetes Education Program, NIDDK,
National Institutes of Health
Pedorthic Footwear Association
Veterans Health Administration,
Louis Stokes Cleveland DVAMC
National Diabetes Education Program, Contract Staff
National Diabetes Education Program, Contract Staff
Christine Tobin, R.N., M.B.A., C.D.E.
David Armstrong, D.P.M.
Robert Frykberg, D.P.M.
Carol Kennedy, R.N., M.A.
Marian Parrott, M.D., M.P.H.
Robert Anderson, M.D.
Pam Colman, D.P.M.
Sharley Chen, Director
Melinda Salmon, Public Health Advisor
Dawn Satterfield, C.D.E.
Ann Corken, R.Ph, M.P.H.
Connie Forster
Sharon Hippler
Fred Pintz, M.D.
Leslie Shainline, R.N.C., M.S.
Stephen Rith-Najarian, M.D.
Lorraine Valdez, R.N., M.P.A., C.D.E.
Shira Kandel
Joanne Gallivan, M.S., R.D.
Mimi Lising, M.P.H.
Nancy Hultquist
Jeffrey Robbins, D.P.M.

Elizabeth Warren-Boulton, R.N., M.S.N., C.D.E.
Rachel Greenberg, M.A.
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I n t ro d u c t i o n. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
T O O L S F O R D IA B E T E S F O O T E X A M S
Tools for Diabetes Foot Exams 4
Flow Chart for Diabetes Foot Exams 5
Diabetes Foot Exam Pro c e d u re s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Quality of Care Measure s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Foot Exam Instru c t i o n s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Visual Foot Inspection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Annual Comprehensive Diabetes Foot Exam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Annual Comprehensive Diabetes Foot Exam Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
M E D I C A R E I N F O R M AT I O N
M e d i c a re Coverage of Therapeutic Footwear for People with Diabetes. . . . . . . . 1 8
Statement of Certifying Physician for Therapeutic Footwear. . . . . . . . . . . . . . . . . . . . . . . . . . 1 9
P rescription Form for Therapeutic Footwear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 9
R E F E R E N C E A N D R E S O U RC E M AT E R I A L S
P revention and Early Intervention for Diabetes Foot Problems:
A Research Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2
R e s o u r ce List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 5
PAT I EN T E D UC AT I O N M AT E R I A L S
" Take Care of Your Feet For A Lifetime"—Foot Care Ti p s
for People with Diabetes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
" To Do" List—for People with Diabetes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 5
A D D I T I O N A L T O O L S
High Risk Feet Stickers for Medical Record
Flyers for Exam Room—in English and Spanish
Quick Reference Pocket Card with Disposable 5.07 (10gram)
Monofilament Attached (See insert at page 15)

C o n t e n t s o f t h e K i t
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N
ational Hospital Discharge Survey Data indicate that 86,000 people with diabetes in the United States
underwent one or more lower-extremity amputations in 1996. Diabetes is the leading cause of amputa-
tion of the lower limbs. Yet it is clear that as many as half of these amputations might be prevented through sim-
ple but effective foot care practices. The 1993 landmark study, the Diabetes Control and Complications Trial
funded by the National Institute of Diabetes and Digestive and Kidney Diseases, conclusively showed that keep-
ing blood glucose, as measured by hemoglobin A1c, as close to normal as possible significantly slows the onset
and progression of diabetic nerve and vascular complications, which can lead to lower extremity amputations.
I n t r o d u c t i o n
People who have diabetes are vulnerable to nerve
and vascular damage that can result in loss of protec-
tive sensation in the feet, poor circulation, and poor
healing of foot ulcers. All of these conditions con-
tribute to the high amputation rate in people with
diabetes. The absence of nerve and vascular symp-
toms, however, does not mean that a patient’s feet are
not at risk. Risk of ulceration cannot be assessed with-
out careful examination of the patient’s bare feet.
Early identification of foot problems and early
intervention to prevent problems from worsening can
avert many amputations. Good foot care, therefore, is
an essential part of diabetes management – for
patients as well as for health care providers.
This kit is designed for primary care and other
health care providers who counsel people with dia-
betes about preventive health care practices, particu-
larly foot care. “Feet Can Last a Lifetime” is designed

to help you implement four basic steps for preventive
foot care in your practice:
Early identification of the high risk diabetic foot.
Early diagnosis of foot problems.
Early intervention to prevent further
deterioration that may lead to amputation.
Patient education for proper care of the
feet and footwear.
The kit includes all of the tools you need to
identify and diagnose foot problems and to
educate your patients:
• A quick-reference pocket card on preventing
diabetes foot problems.
• A disposable monofilament for sensory testing
(attached to pocket card).
• Instructions for a visual foot inspection.
• Instructions and a reproducible form for an
annual comprehensive foot exam.
• Prescription forms to facilitate Medicare
coverage of therapeutic footwear.
• Additional tools to facilitate visual and
comprehensive foot exams.
• A review of current research.
• A list of additional resources.
• Patient education materials.
All of the materials in the kit may be
reproduced without permission and shared
with colleagues and patients. Feel free to
duplicate the copier- ready masters for
your practice. To obtain additional copies of

this kit, “Take Care of Your Feet for a
Lifetime” companion booklets, and other
diabetes information for your patients, call
1-800-438-5383 or visit the NDEP website at
on the Internet.
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To o l s f o r
D i a b e t e s
F o o t E x a m s
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To o l s f o r D i a b e t e s F o o t E x a m s
T
he following section provides tools to help you and your staff incorporate diabetes foot exams into clinical
practice and improve patient outcomes. Research indicates that when tools like these are used by
providers, more examinations of lower extremities are performed, patients at risk for amputation are identified,
and more patients are referred for podiatric care.
1
Using these tools also will help providers meet the Healthy
People 2010 Diabetes Objectives that include increasing the proportion of persons with diabetes who have at
least an annual foot examination and reducing the frequency of foot ulcers and lower extremity amputations in
persons with diabetes.
Current clinical recommendations call for a com-
prehensive foot examination at least once a year for all
people with diabetes to identify high risk foot condi-
tions. People with one or more high risk foot condi-
tions should be evaluated more frequently for the
development of additional risk factors. People with
neuropathy should have a visual inspection of their
feet at every contact with a health care provider.

2
In communities where the prevalence and
incidence of diabetes foot problems are high,
providers may determine that inspecting feet
at every visit – for both low and high risk
patients – is warranted.
The following tools will help you incorporate
diabetes foot exams into your practice.
Flow Chart for Diabetes Foot Exams – depicts the
desired sequence of exams for patients with low-risk
or high-risk feet.
Diabetes Foot Exam Procedures – explains
the recommended procedures for conducting compre-
hensive foot examinations and visual inspections.
Quality of Care Measures – specifies ways in which
documented foot care practices can be audited to
indicate short, intermediate, and long-term outcomes.
These outcomes can be used by providers to improve
diabetes foot care performance.
Foot Exam Instructions – provides step-by-step
instructions for completing a visual inspection of the
feet and an annual comprehensive foot exam.
Annual Comprehensive Diabetes Foot Exam
Form – documents inspection of skin, hair, and nails,
examination of musculoskeletal structures, pedal puls-
es, and protective sensation, assessment of risk for foot
problems, assessment of footwear, and completing a
management plan.
See “Additional Tools” for these items:
High Risk Feet Stickers – designed for cre a t i n g

brightly colored “high risk” feet stickers on Ave ry
labels to place on the medical re c o rd.
E x a m i n a t i o nR o o mF l y e r s (English and Spanish) –
encourage patients to re m ove shoes and socks in
p reparation for a foot exam.
1
Litzelman DK, Slemenda CW, Langefeld, CD, et al. Reduction of lower extremity clinical abnormalities in patients with non-
insulin-dependent diabetes mellitus. Annals of Internal Medicine 119(1):36-41, 1993.
2
American Diabetes Association: Clinical Practice Recommendations 2000. Diabetes Care 2000:23(Suppl.1);S55-56.
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F l o w C h a r t f o r D i a b e t e s F o o t E x a m s *
*Adapted from Population-Based Guidelines for Diabetes Mellitus. Health Promotion and Chronic Disease
Prevention Program, Oregon Health Division and Oregon Department of Human Resources, 1997.
S t a r t
Type 1 and Type 2: when diagnosed
Annual Comprehensive Foot Exam and
Risk Categorization
Include education for self-care of feet
and reassess metabolic control.
Low
Risk
Feet
Visually
inspect
feet as
warranted
Visually
inspect

feet at
every visit
Management
plan to support
self-care of
the feet and
identification of
foot problems
Management
plan to restore
and/or
maintain
integrity of
the feet
High
Risk
Feet
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D i a b e t e s F o o t E x a m P r o c e d u r e s
C a t e g o r y of Patient
Persons with:
• Type 1 diabetes
• Type 2 diabetes
Persons at:
• High risk
• Low risk
(Refer to chart on page 13 for
definitions of risk)
Recommended Pro c e d u r e

C o m p rehensive foot exam to identify high
risk foot conditions. A physician or other
trained health care provider should:
• Assess skin, hair and nails, muscu-
loskeletal stru c t u re, vascular status,
and protective sensation.
• Inspect footwear for blood or other
d i s c h a rge, abnormal wear patterns,
f o r eign objects, proper fit, appro p r i-
ate material, and foot pro t e c t i o n .
• Educate about self-care of the feet.
• Educate about the importance of
blood glucose monitoring including
the use of the Hemoglobin A1c test.
• Reassess metabolic contro l .
Management plan.
• The subsequent foot care manage-
ment plan depends on risk category,
foot status, and metabolic control.
• High risk patients should be re f e rre d
to a health care provider with train-
ing in foot care .
Visual foot inspection to identify foot
p roblems. A physician or other trained
s t a ff should perf o r m the foot inspection.
F re q u e n c y
Annually or
when a new
abnormality
is noted

At every visit
As warranted
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Q u a l i t y o f C a re M e a s u re s
Clinical Documentation
The following should be document-
ed in the medical record:
• Results of the annual
comprehensive foot
examination including
risk assessment.
• Results of the visual
foot inspection.
• Occurrence of patient
education.
* This is the only action needed for providers to be in accord with the foot care component of a current set of
national quality improvement measures. The Diabetes Quality Improvement Project (DQIP) is a collaborative
effort to improve diabetes care and the quality of life for people with diabetes. DQIP uses a set of eight
performance measures for diabetes, one of which specifies that “an annual foot exam for adults with diabetes”
be documented.
Numerous public agencies (the Department of Defense, the Health Care Financing Administration, the Indian
Health Service, and the Veterans Health Administration) and private groups (the American Diabetes Association
Provider Recognition Program and the National Committee for Quality Assurance) are using some or all
of the DQIP measures.
M e a s u re s
Short-term Impact: A successful program will show an
increase in the percentage of the population with diabetes
for whom the following is documented:
• A comprehensive foot exam and risk assessment

in the past year.*
• A visual foot inspection at each routine visit in
the past year.
• Foot care education in the past year.
A survey could be conducted to ask patients to report when
they last had a sensory test, foot inspection, and self-care
education in the past year.
Intermediate-term Impact: A successful program will show a
decrease in the incidence of hospital admissions or emer-
gency room visits for lower extremity infections,
osteomyelitis, and ulcerations.
Long-term Outcomes: A successful program will show a
decrease in the incidence of distal and proximal lower
extremity amputations.
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F o o t E x a m I n s t r u c t i o n s
Visual Foot Inspection
Objectives
• Quickly identify an obvious foot problem.
• Document foot inspection findings.
• Determine the need for a comprehensive foot exam.
• Schedule follow-up care and referrals.
Instructions
A physician, nurse, or other trained staff may complete this inspection.
1. Inspect the foot between the toes and from toe to heel. Examine the skin for injury, calluses, blisters,
fissure, ulcers, or any unusual condition.
2. Look for thin, fragile, shiny, and hairless skin—all signs of decreased vascular supply.
3. Feel the feet for excessive warmth and dryness.
4. Remove any nail polish. Inspect nails for thickening, ingrown corners, length, and

fungal infection.
5. Inspect socks or hose for blood or other discharge.
6. Examine footwear for torn linings, foreign objects, breathable materials, abnormal wear
patterns, and proper fit.
7. If any new foot abnormality is found, the patient should be scheduled immediately
for a comprehensive foot examination.
8. Document findings in the medical record.
Frequency of Inspection
Current clinical recommendations
1
call for visual inspection of the feet:
• At every visit for people who have neuropathy.
• At least twice a year for people with one or more high risk* foot conditions to screen for the devel-
opment of additional risk factors.
• At least annually, or more often if warranted, for low risk feet.*
In populations where the prevalence and incidence of diabetes foot problems are high, providers
may determine that inspection of the feet at every visit — for both low and high risk patients — is
warranted. To facilitate foot inspection and examination, consider adopting a policy such as “For all
patients with diabetes, remove shoes and socks in preparation for examination.”
*Refer to chart on page 13 for definitions of risk.
1
American Diabetes Association: Clinical Practice Recommendations 2000. Diabetes Care 2000:23(Suppl.1); S55-56.
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Annual Comprehensive Diabetes Foot Exam
Objectives
Completing the comprehensive annual foot exam will enable you to:
Instructions
Use copies of the annual comprehensive foot exam form to document findings, or incorporate the
assessment questions and foot exam into an already existing overall diabetes care plan. A physician or

other trained health care provider should conduct the foot exam. Prepare the patient for examination
by removing shoes and socks/hose.
I. Presence of Diabetes Complications Complete the questions as directed.
Question 1: Does the patient have any history of the macro- and micro-vascular complications of dia-
betes or a previous amputation?
Patients who have been diagnosed with peripheral neuro p a t h y, nephro p a t h y, re t i n o p a t h y, peripheral
vascular disease or cardiovascular disease are likely to have had diabetes for several years and to be at
risk for diabetes foot problems. A positive history of a previous amputation places the patient perm a-
nently in the high risk category. Specify the type and date of amputation(s).
Question 2: Does the patient have a foot ulcer now or a history of foot ulcer?
A positive history of a foot ulcer places the patient permanently in the high risk category. This per-
son always has an increased risk for developing another foot ulcer, progressive deformity of the
foot, and ultimately, lower limb amputation.
II. Current History Complete the questions as directed.
Question 1: Is there pain in the calf muscles when walking—i.e., pain occurring in the calf or thigh
when walking less than one block that is relieved by rest?
This question is to determine whether the patient experiences intermittent claudication when walk-
ing. This pain is an indication of peripheral vascular disease or impaired circulation.
Question 2: Has the patient noticed any changes in the feet since the last foot exam?
Patients may notice changes in skin and nail condition or sensory perception if they are
performing self-tests with a monofilament.
• Collect the necessary data to assess feet for risk
of complications.
• D e t e r mine the patient’s risk status.
• Document foot exam findings.
• D e t e r mine the need for therapeutic foot wear.
• D e t e rmine the need for re f e rral to foot care
s p e c i a l i s t s .
• Schedule self-management education.
• Develop an appropriate management plan.

• Schedule follow-up care and re f e rr a l s .
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Questions 3 and 4: Has the patient experienced any shoe problems? Has the patient noticed any
blood or other discharge in socks or hose?
New shoes can cause unexpected pressure and irritate underlying skin. Blood or other
discharge from a foot wound can be the first indication of a severe foot problem.
Question 5: What is the patient's smoking history?
Cigarette smoking is a major risk factor for microvascular and macrovascular disease and is
likely to contribute to diabetes foot disease.
Question 6: What is the patient’s most recent hemoglobin A1c test result?
Elevated hemoglobin A1c values are independently associated with a twofold risk
of amputation.
III. Foot Exam Complete the questions or fill in the items as directed.
Item 1. Condition of the skin, hair and toenails.
Questions: Is the skin thin, fragile, shiny and hairless? Are the nails thick, too long, ingrown, or
infected with fungal disease?
• Examine each foot between the toes and from toe to heel. Record any problems by drawing or
labeling the condition on the foot diagram. Skin that is thin, fragile, shiny, and hairless is an indica-
tion of decreased vascular supply. Loss of sweating function may cause cracking of the skin and fis-
s u res that can become infected.
• Remove any nail polish. Check toenails to see if they are ingrown, deformed, or fungal. Thick
nails may indicate vascular or fungal disease. If severe nail or dry skin problems are present,
refer the patient to a podiatrist or a nurse foot care specialist.
Measure, draw in, and label the patient’s skin condition.
• Measure and draw on the form any corns, calluses, pre-ulcerative lesions (a closed lesion,
such as a blister or hematoma), or open ulcers.
• Use the appropriate symbol to indicate what type of lesion is present—i.e., callus, ulcer,
redness, warmth, maceration, pre-ulcerative lesion, fissure, swelling or dryness. Maceration
is present if the tissue is friable, moist, and soft.

• Label areas that are significantly dry, red, or warm (warmer than other parts of the foot
or the opposite foot).
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Item 2: Musculoskeletal Deformities
• Foot deformities may be the result of diabetic motor neuropathy. The function of intrinsic
muscles is lost, causing the toe digits to buckle as other muscles become imbalanced. Muscle
wasting occurs. The plantar fat pad becomes displaced and the metatarsal heads become
more prominent. Limited joint mobility occurs and contributes to the potential for toe and
foot injury. If Charcot foot is present, there are severe bone and joint changes and the foot
is swollen and warm to the touch.
• Indicate any of the foot deformities listed—i.e., toe deformities, bunions, foot drop, prominent
metatarsal heads, or Charcot foot. The more serious deformities are illustrated above. Prominent
metatarsal heads are evidence of major deformity such as midfoot collapse.
Item 3: Pedal Pulses
Check the pedal pulses (posterior tibial and dorsalis pedis) in both feet and note whether pulses are
present or absent.
Hammer Toes Claw Toes
Bunions
(Hallux Valgus)
Plantar View of
Charcot Joint
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1413
Item 4: Sensory Exam
The sensory testing device supplied in this kit is a 5.07 (10-gram) Semmes-Weinstein nylon monofila-
ment mounted on a holder that has been standardized to deliver a 10-gram force when properly
applied. Research has shown that a person who can feel the 10-gram filament in the selected sites is
at reduced risk for developing ulcers. Because sensory deficits appear first in the most distal portions

of the foot and progress proximally in a “stocking” distribution, the toes are the first areas to lose
protective sensation.
• The sensory exam should be done in a quiet and relaxed setting. The patient must not watch
while the examiner applies the filament.
• Test the monofilament on the patient’s hand so he/she knows what to anticipate.
• The five sites to be tested are indicated on the examination form.
• Apply the monofilament perpendicular to the skin’s surface (see diagram A below).
• Apply sufficient force to cause the filament to bend or buckle, using a smooth, not a jabbing
motion (see diagram B below).
• The total duration of the approach, skin contact, and departure of the filament at each site
should be approximately 1 to 2 seconds.
• Apply the filament along the perimeter and NOT ON an ulcer site, callus, scar or necrotic tissue.
Do not allow the filament to slide across the skin or make repetitive contact at the test site.
• Press the filament to the skin such that it buckles at one of two times as you say “time one” or
“time two.” Have patients identify at which time they were touched. Randomize the sequence of
applying the filament throughout the examination.
• To order additional disposable or reusable monofilaments, see the Resource List on page 35.
IV. Risk Categorization
Based on the foot exam, determine the patient’s risk category. A definition of “low risk” or “high risk”
for recurrent ulceration and ultimately, amputation, is provided in the following chart, along with
minimum suggested management guidelines. Individuals who are identified as high risk may require a
more comprehensive evaluation.
See the Resource List for obtaining information about other foot exam forms and risk categorization
schemes developed by the Bureau of Primary Health Care’s Lower Extremity Amputation Prevention
(LEAP) Program, Health Care Financing Administration, and the Veterans Administration.
A B
Apply the monofilament perpendicular
to the skin’s surface.
Apply sufficient force to cause the
filament to bend or buckle.

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Risk Category
D e f i n e d
Low Risk Patients
None of the five high risk
characteristics below.
High Risk Patients
One or more of the following:
Loss of protective sensation
Absent pedal pulses
Foot deformity
History of foot ulcer
Prior amputation
Management Guidelines
• Perform an annual comprehensive foot exam.
• Assess/recommend appropriate footwear.
• Provide patient education for preventive self-care.
• Perform visual foot inspection at provider’s discretion.
• Perform an annual comprehensive foot exam.
• Perform visual foot inspection at every visit.
• Demonstrate preventive self-care of the feet.
• Refer to specialists and an educator as indicated.
(Always refer to a specialist if Charcot foot is suspected.)
• Assess/prescribe appropriate footwear.
• Certify Medicare patients for therapeutic shoe benefits.
• Place a “High Risk Feet” sticker on the medical record.
Management Guidelines for Active Ulcer or Foot Infection
• Never let patients with an open plantar ulcer walk out in their own shoes.

Weight relief must be provided.
• Assess/prescribe therapeutic footwear to help modify weight bearing and protect
the feet.
• Conduct frequent wound assessment and provide care as indicated.
• Demonstrate preventive self-care of the feet.
• Provide patient education on wound care.
• Refer to specialists and a diabetes educator as indicated.
• Certify Medicare patients for therapeutic footwear benefits.
• Place a “High Risk Feet” sticker on the medical record.
Once feet are categorized as high risk, it is unlikely that risk status will change unless vascular sur-
gery is performed. At subsequent visits the provider should assess for the development of additional
risk factors and focus on maintaining the integrity of the feet and on metabolic control. Patients
should be educated about avoidance of injury, use of therapeutic footwear, and preventive self-care.
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14
V. Footwear Assessment
Question 1. Does the patient wear appropriate shoes?
Question 2. Does the patient need inserts?
Question 3. Should corrective footwear be prescribed?
Check inside shoes for foreign objects, torn lining, and proper cushioning. Improper or poorly fitting
shoes are major contributors to diabetes foot ulcerations. Counsel patients about appropriate
footwear. All patients with diabetes need to pay special attention to the fit and style of their shoes
and should avoid pointed-toe and open-toe shoes, high heels, thongs and sandals. Assess the material
and construction of footwear. Unbreathable and inelastic materials such as plastic should be avoided.
Recommend use of materials such as canvas, leather, suede, and other materials that are breathable
and/or elastic. Footwear should be adjustable with laces, Velcro, or buckles. Record the results of your
footwear assessment.
Properly fitted athletic or walking shoes are recommended for daily wear. If off-the-shelf shoes are
used, make sure that there is room to accommodate any deformities. High risk patients may require
depth-inlay shoes or custom-molded inserts (orthoses), depending on the degree of foot deformity

and history of ulceration. (See Medicare Coverage of Therapeutic Footwear on page 18.)
VI. Education
Question 1: Has the patient had prior foot care and other relevant diabetes education?
Question 2: Can the patient demonstrate appropriate foot care?
Indicate whether the patient has received prior education by checking yes or no in the blank.
Patient education about foot care and other aspects of self-care is an essential component of
preventive diabetes care. Observe whether the patient can demonstrate appropriate self-care
of the feet. Refer for smoking cessation counseling if necessary. Determine whether the patient
understands the need for, and results of, hemoglobin A1c tests.
VII. Management Plan
Complete the management plan, indicating actions for patient education, any diagnostic tests
including hemoglobin A1c, footwear recommendations, referrals, and follow-up care.
Note: The management of foot problems may be the responsibility of different health care providers.
For example, in some communities, certified nurses provide home health services or practice in primary
care or foot care clinics to provide specialized diabetes foot care.
Shoes must protect and
support the feet.
Shoes must accommodate
foot deformities.
Shoe shape must match foot shape.
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IV. Risk Categorization Check appropriate box.
V. Footwear Assessment Indicate yes or no.
1. Does the patient wear appropriate shoes? Y___ N ___
2. Does the patient need inserts? Y ___ N ___
3. Should corrective footwear be prescribed? Y ___ N ___
VI. Education Indicate yes or no.
1. Has the patient had prior foot care education? Y __N__
2. Can the patient demonstrate appropriate foot care? Y__N__
3. Does the patient need smoking cessation counseling?

Y__N__
4. Does the patient need education about HbA1c or other
diabetes self-care? Y__N
Provider Signature
VII. Management Plan Check all that apply.
1. Self-management education:
Provide patient education for preventive foot care. Date:
Provide or refer for smoking cessation counseling. Date:
Provide patient education about HbA1c or other aspect
of self-care. Date: _ _ _ _ _ _ _ _
2. Diagnostic studies:
❏ Vascular Laboratory
❏ Hemoglobin A1c (at least twice per year)
❏ Other: _________
3. Footwear recommendations:
4. Refer to:
5. Follow-up Care:
Schedule follow-up visit. Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
15
Annual Comprehensive Diabetes Foot Exam Form
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: ___________________ ID#: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
I. Presence of Diabetes Complications
1. Check all that apply.
❏ Peripheral Neuropathy
❏ Nephropathy
❏ Retinopathy
❏ Peripheral Vascular Disease
❏ Cardiovascular Disease
❏ Amputation (Specify date, side, and level)
______________________________________

Current ulcer or history of a foot ulcer?
Y____ N____
For Sections II & III, fill in the blanks
with “Y ” or “N” or with an “R,” “L,” or
“B” for positive findings on the right,
left, or both feet.
II. Current History
1. Is there pain in the calf muscles when
walking that is relieved by rest?
Y____ N____
2. Any change in the foot since the last
evaluation? Y ____ N____
3. Any shoe problems? Y___ N____
4. Any blood or discharge on socks or
hose? Y____ N____
5. Smoking history? Y___N___
6. Most recent hemoglobin A1c result
______% ________ date
III. Foot Exam
1. Skin, Hair, and Nail Condition
Is the skin thin, fragile, shiny and
hairless? Y ___ N___
Are the nails thick, too long,
ingrown, or infected with fungal
disease? Y ___ N___
Measure, draw in, and label the
patient’s skin condition, using the key
and the foot diagram below.
C=Callus U=Ulcer PU=Pre-Ulcer
F=Fissure M=Maceration R=Redness

S=Swelling W=Warmth D=Dryness
2. Note Musculoskeletal Deformities
❏ Toe deformities
❏ Bunions (Hallus Valgus)
❏ Charcot foot
❏ Foot drop
❏ Prominent Metatarsal Heads
3. Pedal Pulses Fill in the blanks with a
“P” or an “A” to indicate present or
absent.
Posterior tibial Left_____ Right_____
Dorsalis pedis Left_____ Right_____
❏ Low Risk Patient
All of the following:
❏ Intact protective sensation
❏ Pedal pulses present
❏ No deformity
❏ No prior foot ulcer
❏ No amputation
❏ High Risk Patient
One or more of the
following:
❏ Loss of protective
sensation
❏ Absent pedal pulses
❏ Foot deformity
❏ History of foot ulcer
❏ Prior amputation
❏ None
❏ Athletic shoes

❏ Accommodative inserts
❏ Custom shoes
❏ Depth shoes
❏ Primary Care Provider
❏ Diabetes Educator
❏ Podiatrist
❏ RN Foot Specialist
❏ Pedorthist
❏ Orthotist
❏ Endocrinologist
❏ Vascular Surgeon
❏ Foot Surgeon
❏ Rehab. Specialist
❏ Other: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4. Sensory Foot Exam Label sensory level with a “+” in the five circled areas of the foot if the patient can feel the 5.07 (10-gram)
Semmes-Weinstein nylon monofilament and “-” if the patient cannot feel the filament.
Right Foot Left Foot
Notes
Notes
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M e d i c a r e
I n f o r m a t i o n
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18
M e d i c a r e C o v e r a g e o f T h e r a p e u t i c
F o o t w e a r f o r P e o p l e W i t h D i a b e t e s
M
e d i c a re provides coverage for depth-inlay shoes, custom-molded shoes, and shoe inserts for people with
diabetes who qualify under Me d i c a r e Pa rt B. Designed to pre vent lower-limb ulcers and amputations in
people who have diabetes, this Me d i c a r e benefit can pre vent suffering and save money.

How Individuals Qualify
The M.D. or D.O. treating the patient for diabetes
must certify that the individual:
1. Has diabetes.
2. Has one or more of the following conditions in one
or both feet:
• history of partial or complete foot amputation
• history of previous foot ulceration
• history of pre-ulcerative callus
• peripheral neuropathy with evidence of callus
f o r m a t i o n
• poor circulation
• foot deformity
3. Is being treated under a comprehensive diabetes
care plan and needs therapeutic shoes and/or
inserts because of diabetes.
Type of Footwear Covered
If an individual qualifies, he/she is limited to one
of the following footwear categories within each
calendar year:
1. One pair of depth shoes and three pairs of inserts
2. One pair of custom-molded shoes (including
inserts) and two additional pairs of inserts.
Separate inserts may be covered under certain criteria.
Shoe modification is covered as a substitute for an
insert, and a custom-molded shoe is covered when the
individual has a foot deformity that cannot be accom-
modated by a depth shoe.
What the Physician Needs to Do
1. The certifying physician (the M.D. or D.O.) over-

seeing the diabetes treatment must review and sign a
“Statement of Certifying Physician for Therapeutic
Shoes” (see form on page 19).
2. The prescribing physician (the D.P.M., D.O.,
or M.D.) must complete a footwear prescription
(see form on page 19). Once the patient has the
signed statement and the prescription, he/she can
see a podiatrist, orthotist, prosthetist or pedorthist
to have the prescription filled. The supplier will
then submit the Medicare claim form (Form
HCFA 1500) to the appropriate Durable Medical
Equipment Regional Carrier (DMERC), keeping
copies of the claim form and the original statement
and prescription.
Note that in most cases, the certifying physician and the
prescribing physician will be two different individuals.
Patient Responsibility for Payment
Medicare will pay for 80% of the payment amount
allowed. The patient is responsible for a minimum
of 20% of the total payment amount and possibly
more if the dispenser does not accept Medicare
assignment and the dispenser’s usual fee is higher
than the payment amount. The maximum payment
amounts per pair as of 2000 are:
ICD-9 codes
Because this benefit is available only to people with
diabetes, an appropriate ICD-9 code
(250.00-250.93) is required when completing the
Statement of Certifying Physician.
Total Amount

Amount Covered by
Allowed Medicare
Depth shoes $126.00 $100.80
Custom-molded shoes $378.00 $302.40
Inserts or modifications 64.00 $51.20
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19
Patient Name: HIC # :
Address:
I certify that all of the following statements are true:
1. This patient has diabetes mellitus. —ICD-9 Code:
(ICD-9 diagnosis codes 250.00-250.93)
2. This patient has one or more of the following conditions (check all that apply):
3. I am treating this patient under a comprehensive plan of care for his/her diabetes.
4. This patient needs special shoes (depth or custom-molded shoes) and/or inserts
because of his/her diabetes.
Certifying Physician Information
Signature: Date:
Name: DEA #
Medicare UPIN # Medicaid Provider #
P rescription Form for Therapeutic Footwear
(Prescribing physician may be different from certifying physician.)
Patient Name: HIC# :
Address:
Diagnosis:
Change to be effected:
Additional relevant information, such as systemic conditions or allergies to specific materials:
Prescribing Physician Information
Signature: Date:
Name: DEA #

Medicare UPIN # Medicaid Provider #
S t a t e m e n t o f C e r t i f y i n g P h y s i c i a n f o r
T h e r a p e u t i c F o o t w e a r
❏ History of partial or complete amputation of
the foot
❏ Peripheral neuropathy with evidence of callus
formation
❏ History of previous foot ulceration
❏ Foot deformity
❏ History of pre-ulcerative callus
❏ Poor circulation
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R e f e r e n c e a n d
R e s o u r ce Materials
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22
The Scope of the Problem
National Goals for Diabetes Foot Care
During their lifetime, 1 5 p e r cent of people
with diabetes will experience a foot ulcer and betwe e n
1 4 and 2 4 p e rcent of those with a foot ulcer will re q u i re
amputation (1). National Hospital Discharge Su rve y
data for 1 9 9 6 indicate that 8 6 , 0 0 0 people with diabetes
u n d e rwent one or more lowe r - e x t r emity amputations
(2). Diabetes is the leading cause of amputation of the
l ower limbs. Yet it is clear that at least half of these
amputations might be pre v ented through simple but
e f f e c t i ve foot care practices.
Healthy People 2010, the U.S. Department of
Health and Human Services’ report (3) that specifies

health objectives for the nation, calls for:
a) An increase in the proportion of people with dia-
betes aged 18 years and older who have at least an
annual foot examination (baseline 55 percent,
target 75 percent).
b) A d e c rease in foot ulcers due to diabetes (baseline
and target figures are “d e ve l o p m e n t a l” ) .
c) A decrease in lower extremity amputations
due to diabetes (baseline 11 per 1,000, target
5 per 1,000 per year). This objective is based on the
estimate that at least 50 percent of the amputations
that occur each year in people with diabetes can be
prevented through screening for high risk patients
and the provision of proper foot care.
Ethnic Groups At Higher Risk for Amputation
Analysis of a statewide California hospital
discharge database indicated that in 1991, the age-
adjusted incidence of diabetes-related lower extremity
amputations per 10,000 people with diabetes was 95.3
in African Americans, 56.0 in non-Hispanic whites,
and 44.4 in Hispanics. Amputations were 1.72 and
2.17 times more likely in African Americans compared
with non-Hispanic whites and Hispanics, respectively.
Hispanics had a higher proportion of amputations
(82.7 percent) associated with diabetes as opposed to
other causes of amputation, than did African
Americans (61.6 percent) or non-Hispanic whites (56.8
percent) (4).
Age-adjusted amputation rates in south Texas in
1993 were 60.68 per 10,000 for non-Hispanic whites,

94.08 for Mexican Americans, and 146.59 for African
Americans (5). The incidence of amputations for Pima
Indians in Arizona was 24.1 per 1,000 person-years
compared to 6.5 per 1,000 person-years for the overall
U.S. population with diabetes (6). Increased awareness
and identification of diabetes-related foot disease is
especially important in these high-risk ethnic groups.
The President’s Initiative to Eliminate Racial and
Ethnic Disparities in Health is focused on eliminating
serious disparities in health access and outcomes expe-
rienced by racial and ethnic minority populations in
six areas of health. Diabetes is one of the targeted
areas. A near term goal for this initiative is to reduce
lower extremity amputation rates among African
Americans with diabetes by 40 percent (7).
P re v e nt i o n an d E a r ly I n t er v e n t io n f o r
D ia b e t e s F o o t Pro b l e m s: A R es e a r c h Re v i e w
R
esearch articles, most published since 1990, were identified and retrieved through computerized searches of
the National Library of Medicine database (MEDLINE). This review is not meant to summarize the entire
literature on the subject, but rather to present a condensation and consolidation of the major findings concerned
with prevention of and early intervention for diabetes foot disease.
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23
Frequency of Foot Examinations
Foot examinations, both by people with diabetes
and their health care providers, are critical preventive
actions. In the 1989 National Health Interview Survey
(NHIS), 52 percent of all people with diabetes stated
that they checked their feet at least daily, but 22 per-

cent stated that they never checked their feet. More
self-exams were reported by insulin-treated individuals
than those who did not use insulin (8).
Estimates of the frequency of provider-performed
annual foot examinations vary. Data from the Centers
for Disease Control’s Behavioral Risk Factor
Surveillance System (BRFSS) indicate that 55 percent
of adults with diabetes ages 18 years and older reported
having at least an annual foot examination by a health
care provider in 1998 (mean value from 39 states) (9).
BRFSS data from 1995 to 1998 indicate that 86.3
percent of people with diabetes had seen a physician
or other health care provider for diabetes care in the
previous 12 months; 67.7 percent of adults with dia-
betes reported having had their feet examined in the
previous 12 months (10). In an earlier nationwide
survey, primary care physicians reported performing
semi-annual foot examinations for 66 percent of
patients with type 1 diabetes and for 52 percent of
patients with type 2 diabetes (11).
Personal and Financial Costs
Diabetes foot disease is a major burden for both the
individual and the health care system and may increase
as the population ages. The total annual cost for the
more than 86,000 amputations is over $1.1 billion dol-
lars. This cost does not include surgeons’ fees, rehabil-
itation costs, prostheses, time lost from work, and dis-
ability payments (12). Regarding quality of life, a study
of patients with diabetes showed that those with
foot ulcers scored significantly lower than those

without foot ulcers in all eight areas of a measure
of physical and social function (13).
Foot disease is the most common complication of
diabetes leading to hospitalization. In 1995, foot dis-
ease accounted for 6 percent of hospital discharges
listing diabetes and lower extremity ulcers, and in
1995 the average hospital stay was 13.7 days. The
average hospital reimbursement from Medicare for
a lower-extremity amputation in 1992 was $10,969,
and from private insurers it was $26,940. At the
same time, rehabilitation was reimbursed at a rate
of $7,000 to $21,000 (14).
Prevalence estimates for ulcers in diabetes patient
populations vary. Fifteen percent of all patients with
diabetes in a population-based study in southern
Wisconsin experienced ulcers or sores on the foot or
ankle. The prevalence increased with age, especially
in patients who were aged 30 or under at diagnosis
of diabetes (15). In a large staff-model health mainte-
nance organization, the incidence, outcomes and costs
of treatment for foot ulcers were studied over two years
in a group of patients with diabetes. In this popula-
tion, the incidence was nearly 2 percent per year and
the direct medical care cost for a 40- to 65-year-old
male with a new foot ulcer was $27,987 over the two
years after diagnosis (16).
After an amputation, the chance of another ampu-
tation of the same extremity or of the opposite extrem-
ity within 5 years is as high as 50 percent. The 5-year
mortality rate after lower extremity amputation ranges

from 39 to 68 percent (8).
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