The Journal for Nurse Practitioners xxx (xxxx) xxx

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The Journal for Nurse Practitioners

journal homepage: www.npjournal.org

Overview of Diabetic Foot Care for the Nurse Practitioner

Jennifer Woody, MSN, FNP-C

a b s t r a c t
Keywords: Foot and ankle complications of diabetes result in significant morbidity, mortality, and health care expen-
Charcot arthropathy diture. Diabetes may result in foot deformity, neuropathy, and peripheral artery disease with risk of callus,
diabetes
foot ulcer, infection, and subsequent amputation. Appropriate patient education, medical management, and
diabetic foot infection
diabetic shoes
use of therapeutic footwear can prevent many diabetic foot complications. Nurse practitioners are key
diabetic ulcer members of foot care teams in both primary and specialty care. The nurse practitioner managing a patient’s
foot care diabetes is an appropriate provider to certify the need for diabetic shoes and should be authorized to do so to
provide quality care without unnecessary delay.
© 2019 Elsevier Inc. All rights reserved.

Foot and ankle complications related to diabetes include
calluses, foot ulcers, infection, bony deformity, and Charcot
arthropathy.1 Thirty-three percent of the $174 billion economic
burden of diabetes is related to foot disease.2 Sixty-eight percent
of people with diabetes experience complications involving
their feet.3 Diabetes is increasing in prevalence and currently
affects more than 29 million individuals in the United States.4
Early intervention through patient education regarding proper
foot care and screening for complications is recommended
through evidence-based guidelines.5 Preventative measures,
including diabetic shoes and inserts, are indicated for in-
dividuals with diabetes and neurological manifestations, pe-
ripheral vascular disease, amputations, significant deformities,
or preulcerations.6
A multidisciplinary approach improves outcomes in diabetic
foot care. The best diabetic foot care is achieved using a team
approach including the patient and clinicians in specialties
including vascular surgery, podiatry, and orthopaedics.2 Spe-
cialty referral should be considered for patients with compli-
cations or impending complications related to their diabetes,
such as diabetic foot ulcers, bony deformity, peripheral vascular
disease, and severe skin, or nail pathology. Nurse practitioners
are integral members of diabetic foot care teams both in pri-
mary and specialty care, providing diabetes management and
patient education, expanding access to care, and improving
outcomes.7
Pathophysiology of Diabetic Foot Complications
Diabetes may result in symmetric polyneuropathy with loss of
proprioception, vibratory perception, temperature perception, and
pressure sensation.8 With decreased sensation and decreased
proprioception, there is repetitive trauma to the foot causing at-
rophy of the plantar fat pad, which can lead to ulceration.8 Atro-
phy of the intrinsic muscles of the foot may lead to clawing of the
toes.8 With the lumbricals and interossei relatively weak, the
stronger pull from the extensor muscles may result in hammer-
toes, and gastrocsoleus contracture causes relative equinus
contracture of the ankle.8 These changes cause increased pressure
on the plantar metatarsal heads. Loss of sensation and repetitive
trauma may result in calluses, blisters, and in fractures that may
not be noticed by the patient. Because of autonomic neuropathy,
the skin is prone to dryness, which can lead to fissuring and
increased risk of cellulitis. With loss of proprioception, patients are
more likely to be unsteady during ambulation and at increased
risk for injury.
Foot Ulcers
One in 4 individuals with diabetes develops a diabetic foot
ulcer.4 Up to one-fourth of these diabetic foot ulcers do not
heal, putting the patient at risk for infection and amputation.
According to a study of more than 1 million patients presenting
to emergency departments in the United States from 2006 to
2010 for diabetic foot ulcers, more than 80% of patients were
admitted, with an annual cost of $8.78 billion.1 Of these
admissions, there was a 2.0% mortality rate, 9.6% of patients
were diagnosed with sepsis, and 10.5% required an
amputation.1
Diabetic foot ulcers are often caused by a combination of bony
deformity, neuropathy, and repetitive trauma.8 There may be delay
in recognizing an ulcer due to lack of sensation and visual

https://doi.org/10.1016/j.nurpra.2019.08.011
1555-4155/© 2019 Elsevier Inc. All rights reserved.
2 J. Woody / The Journal for Nurse Practitioners xxx (xxxx) xxx
limitations of diabetic retinopathy. A patient may continue to walk
on a painless ulcer, resulting in further soft tissue damage. Factors
influencing the risk of amputation include the severity of soft tissue
loss, ischemia, and infection.1 Diabetic foot wounds that do not heal
result in >100,000 amputations in the United States annually, 60%
of which started with a foot ulcer.8
Treatment of a diabetic foot ulcer requires appropriate
debridement, offloading, maximizing perfusion, and infection
management.8 The gold standard for offloading a diabetic foot ulcer
is application of a total contact cast, a cast with plaster molded
closely to the foot and ankle with a fiberglass outer layer for quicker
drying and durability (Figure 1).9 Application of total contact casts
requires technical skill to avoid pressure points and achieve
appropriate foot and ankle alignment. Patients must keep casts dry
and often find them cumbersome and difficult for ambulation. For
this reason, other options, such as a postoperative shoe, padded
dressing, and controlled ankle motion boot, are often used.
Hyperglycemia and altered glucose metabolism result in
hyperlipidemia, increased platelet viscosity, endothelial injury, and
atherosclerosis. Peripheral artery disease is present in 50% to 60% of
patients with a diabetic foot ulcer.1 Compared with neuropathic
ulcers, ulcers resulting from arterial insufficiency carry a higher risk
of recurrence and amputation.4 Presence of palpable pulses is un-
reliable to assess for ischemia.1 The Society for Vascular Surgery
recommends measurement of toe waveforms and pressures in
patients with diabetic foot ulcers because the ankle brachial index
may be falsely elevated due to calcification of the arterial wall. The
degree of perfusion required for healing of a diabetic foot ulcer is
affected by ulcer size, location, depth, infection, and nutritional
status of the patient. In patients with an ulcer, if ankle pressure is
<100 mm Hg or toe pressure is <55 mm Hg, arterial studies are
indicated to evaluate for occlusive lesions that could be addressed
through vascular intervention.
Figure 1. Total contact cast with cast shoe.
Without preventative measures, 58% to 85% of patients with an
ulcer will develop another ulcer within a year.1 Use of therapeutic
shoes and inserts decreases this incidence by about 50%.1 Custom
diabetic inserts are generally multiple density with a soft top layer
and are molded to provide total contact with a patient’s foot. Inserts
can accommodate deformity to equalize pressure and minimize
friction. Patients may need extra-depth shoes, which have a
removable full-length filler that when removed, provides depth to
accommodate custom inserts (Figure 2). Custom molded shoes are
another option and are fabricated over a model of a patient’s foot
and include custom inserts.6 Extra-depth shoes or custom-molded
shoes can be modified with rocker bottoms or metatarsal bars to
offload the metatarsal heads, posting or wedges to shift weight
laterally, and offset heels to stabilize severe hind foot deformity.6
Medicare Part B covers either 1 pair of custom-molded shoes
and inserts or 1 pair of extra-depth shoes per year for patients with
diabetes and severe foot disease. Two additional pairs of inserts are
covered per calendar year for the custom-molded shoes, and 3
additional pairs of inserts for the extra-depth shoes. Patients pay
20% of the Medicare-approved cost as well as the part B deductible
(https://www.medicare.gov/coverage/therapeutic-shoes-inserts).
Foot Infections
In patients with diabetes and risk factors for foot ulcers, off-
loading using appropriate therapeutic inserts and footwear is
imperative to prevent initial ulceration as well as ulcer recurrence
and to decrease the risk of infection. When presenting for care,
approximately half of foot ulcers are infected based on clinical
exam.1 An ulcer present for more than 30 days is at higher risk for
infection.10 Additional risk factors for infection include presence of
peripheral arterial disease, peripheral neuropathy, renal impair-
ment, prior lower extremity amputation, and walking without
Figure 2. Diabetic depth shoe and custom insert.
 J. Woody / The Journal for Nurse Practitioners xxx (xxxx) xxx
shoes.10 When glycemic control is poor, leukocyte activity and
complement function are altered increasing the risk of soft tissue
infection. Bacteria may quickly penetrate into the deep fascia in
poorly perfused skin. Foot infections result in 1 in 5 hospital ad-
missions in patients with diabetes.10
Aerobic gram-positive cocci such as Staphylococcus aureus are
the most common pathogen in diabetic foot infections.5 If in-
fections are mild without risk factors for gram-negative patho-
gens, such as recent antibiotic therapy or hospitalization,
ischemia, or gangrene, narrow spectrum antibiotics are appro-
priate.5 Clinicians should consider coverage for methicillin-
resistant Staphylococcus aureus (MRSA) in individuals with a
history of MRSA infection, when MRSA is locally prevalent, and
in severe infections.5 Severe infections should be treated with
broader-spectrum antibiotics.5
In patients with diabetic complications involving the foot and
ankle, osteomyelitis almost always results from extension of
infection from a chronic ulcer.10 Hematogenous infection is
much less likely.10 Osteomyelitis should be suspected if a dia-
betic foot ulcer does not heal in six weeks with appropriate
antibiotic therapy and offloading.5 Ulcers that probe to bone
likely have resulted in osteomyelitis. There is debate regarding
the necessity and extent of surgical debridement indicated in
osteomyelitis.5 Nonsurgical management should be considered
if surgical debridement would result in unacceptable functional
deficit; if there is ischemia due to vascular disease that cannot be
addressed through endovascular or surgical intervention; if
there is limited infection, especially in the forefoot; or the risks
of surgery exceed the benefits.5 Urgent or emergent amputation
is indicated in cases of life-threatening infection or limb ne-
crosis.5 If there is recurrent ulceration without progressive deep
Figure 3. (A) Anterior-posterior and lateral of foot in early Charcot arthropathy (prodromal phase) and (B) Anterior-posterior and lateral of same foot 4 years after that in panel A
with advanced Charcot changes (reconstruction phase).
3
infection despite appropriate preventative measures, elective
amputation may be indicated.5
One to 2 weeks of antibiotic therapy is sufficient for most mild to
moderate soft tissue infections.5 Current data suggests no more
than 6 weeks of antibiotic therapy is required for osteomyelitis with
residual infected bone.11 There is no evidence to support continuing
antibiotics until a diabetic foot ulcer is healed, only until the
infection has been cleared.5
Charcot Arthropathy
Often confused with diabetic foot infection, Charcot arthropathy
is a neuropathic arthropathy most commonly occurring in the
setting of diabetic neuropathy that results in destruction of bone
and soft tissues. It is associated with increased mortality and
decreased quality of life.9 Charcot arthropathy begins with a pro-
dromal phase with erythema, edema, and normal radiographs
(Figure 3A). In the development stage, there are radiographic
findings of osteopenia, bony fragmentation, and joint subluxation
or dislocation.13 The phase of coalescence is characterized by
decreased warmth, edema, and erythema and bony absorption,
sclerosis, and fusion.13 In the reconstruction phase, individuals have
a clinically fixed deformity, bony consolidation on radiographs, and
joint arthrosis (Figure 3B).13 The pathogenesis of Charcot arthrop-
athy is not fully understood but likely explained by the combination
of repetitive trauma in the setting of neuropathy and increased
blood flow to the foot resulting in increased compartment pressure
and deep tissue ischemia.14 Patients with peripheral artery disease
seem to be protected from Charcot arthropathy due to limited
arterial flow, but those with Charcot arthropathy may go on to
subsequently develop peripheral artery disease.14 In Charcot
4 J. Woody / The Journal for Nurse Practitioners xxx (xxxx) xxx

arthropathy, continued weightbearing without offloading may

result in fracture, subluxation, and dislocation most often involving
the midfoot.
The diagnosis of Charcot arthropathy is primarily based on
history and physical exam and requires a high index of suspicion in
patients with neuropathy. Acute Charcot arthropathy is often
confused with cellulitis, deep vein thrombosis, or gout because it
results in a unilateral erythematous, edematous foot and ankle,
which may or may not be painful. Unlike infection, the erythema
associated with Charcot arthropathy will decrease with several
minutes of elevation. Less than 50% of patients with Charcot
arthropathy are aware of their neuropathy, and patients may report
that they have normal sensation.12 As many as 40% of patients have
an ulcer when they are first diagnosed with Charcot arthropathy.12
Presence of streaking erythema is not consistent with Charcot
arthropathy and is suggestive of infection.14 In Charcot arthropathy,
the foot is warmer to the touch than the contralateral side, often
increased by 3 to 5 degrees Celsius.12 Pulses are generally palpable
and often bounding.12 When presenting early in the disease pro-
cess, radiographs are often normal, but the diagnosis is clinical, and
advanced imaging is typically not required.12 As Charcot arthrop-
athy progresses, radiographs show evidence of bony resorption and
collapse of the medial longitudinal arch resulting in a “rocker-
bottom” deformity.12,14
Patients with suspected Charcot arthropathy should be
referred to orthopaedics or podiatry early to manage symptoms
and minimize deformity.1 Initial treatment involves immobili-
zation and avoiding weightbearing until edema decreases and
there is no further progression of radiographic changes.15 Figure 4. Charcot Restraint Orthotic Walker (CROW).
Traditional treatment is non-weightbearing in a total contact
cast until edema decreases and x-rays stabilize, which may
require between 9 weeks and 11 months in a cast.14 A total arthropathy require an amputation at the ankle or more proximal.16
contact cast redistributes plantar pressure, reduces inflamma- This rate increases to 35% to 67% in patients with a related diabetic
tion and edema, and limits bone and joint destruction associated foot ulcer.12 Historically, surgery has been performed to address
with Charcot arthropathy.9 Recent studies suggest weightbear- deformity related to Charcot arthropathy, in cases of chronic oste-
ing in a total contact cast may not adversely affect outcomes.14 omyelitis, chronic wounds over a bony deformity, or in severe
During the acute Charcot phase, casts are changed every 1 to 2 deformity that cannot be accommodated with a brace or orthotic
weeks or more frequently to monitor skin and ensure appro- device.17 In the past, nonoperative treatment was considered suc-
priate cast fit as edema decreases.15 While total contact casting is cessful if infection was cleared and the deformity could be
considered the gold standard for treatment of Charcot arthrop- accommodated with a CROW, AFO, or custom insert or shoe.17
athy, it carries risks of ulceration and deep vein thrombosis, is However, more recent studies have indicated that quality of life of
challenging from mobility and bathing standpoints, and requires patients is impaired after Charcot arthropathy when patients
technical skill and time in clinic. Removable boots allow patients require cumbersome orthotic devices such as a CROW.17 Surgery is
to check their skin daily and offload the forefoot and midfoot now considered an option to achieve a plantigrade foot and allow
while loading the hindfoot. There are mixed results when using patients to use therapeutic shoes.17 The decision for surgery must
boots for Charcot arthropathy involving the midfoot compared take into account the patient’s desires, ability to comply with
to nonremovable total contact casts.14 treatment recommendations, social support, and comorbidities.
After the acute inflammatory phase has resolved, patients may Often a patient has diabetes for more than 10 years, is morbidly
transition to a Charcot restraint orthotic walker (CROW), which is a obese, has long-standing peripheral neuropathy, immune defi-
fully lined boot with custom foot insert intended for patients with ciency, vitamin D deficiency, and osteoporosis, all factors that
severe deformity due to neuropathic arthropathy (Figure 4).15 The should be considered when evaluating the risks and benefits of
top and bottom of the boot are secured with straps to enclose the surgery.17
foot and ankle completely. Alternatively or after a period in a
CROW, an ankle foot orthotic (AFO) may be used in combination Screening and Preventative Measures
with an extra-depth shoe and insert or custom shoe to control the
ankle instability associated with Charcot arthropathy. A conven- Avoiding foot and ankle complications of diabetes requires
tional AFO typically is constructed of two metal upright bars appropriate screening, medical management of diabetes, and
extending from the sole of the shoe past the ankle to a leather calf patient education. The recommendation is to achieve a hemo-
strap (Figure 5). If the ankle is stable, patients may transition to an globin a1c of <7% when appropriate to reduce the risk of diabetic
extra-depth shoe with diabetic insert following acute Charcot foot ulcer, infection, and subsequent risk of amputation.4 The
arthropathy (Figure 2). Patients with severe deformity may benefit American Diabetes Association recommends a foot exam at least
from operative reconstruction.15 annually for all patients with diabetes.1 Those at increased risk
Fifty percent of patients with Charcot arthropathy require at with substantial neuropathy or peripheral arterial disease
least 1 surgery.12 Fifteen percent of patients with Charcot should be assessed more frequently.1 Skin should be inspected
 J. Woody / The Journal for Nurse Practitioners xxx (xxxx) xxx
Figure 5. Conventional ankle foot orthotic (AFO).
for evidence of trauma, callus, ulceration, and foot or toe
deformity. Posterior tibial, dorsalis pedis, and popliteal pulses
should be palpated. If pulses are not palpable, Doppler should be
utilized.8 Clinicians should assess for rest pain and dependent
rubor, which are evidence of tissue ischemia. A thorough
neurological exam should include evaluation of vibratory sense
with a 128-Hz tuning fork, sensation with a Semmes-Weinstein
5.07 monofilament, temperature, and Achilles and patellar re-
flexes.8 Abnormal findings indicate increased risk of develop-
ment of a diabetic foot ulcer.8 Patients should be evaluated for
issues with gait and balance. It is recommended that patients
with a diabetic foot ulcer have an annual ankle-brachial index,
pedal and ankle Doppler arterial waveforms, and toe systolic
pressure or transcutaneous oxygen pressure to assess the po-
tential for ulcer healing and evaluate whether vascular inter-
vention is indicated to improve healing potential. 4 Although
often ordered by vascular specialists, these tests should be
considered by any provider treating a diabetic ulcer.
Patients with diabetic neuropathy should be educated
regarding sensory loss and should check their skin daily for
blisters, calluses, erythema, and ulceration. Feet should be
washed and dried daily, avoiding residual moisture between the
toes. Lotion should be applied to the dorsal and plantar surfaces
of the foot but not between the toes.18 Nails should be trimmed
straight across, filing sharp edges with a nail file to avoid
ingrown nails.18 To remove a callus, patients should gently rub a
wet pumice stone over the callus after bathing.18 While safer
than using chemical agents on calluses, patients with neuropa-
thy should use caution with pumice stones because of the
increased potential for skin injury. Shoes should be checked
before wearing to ensure nothing is in the shoe that could result
in added pressure. Those with bony deformities such as ham-
mertoes may need extra-depth shoes. Custom shoes are often
5
necessary for patients with severe deformities. Patients should
be counseled to break in shoes gradually. Those with neuropathy
should avoid walking without shoes because this increases the
risk of wounds.18
Barrier to Care for Patients of Nurse Practitioners
Currently, Medicare requires a physician treating the pa-
tient’s diabetes to certify the necessity of diabetic shoes or in-
serts.6 According to Medicare guidelines, providers
knowledgeable regarding the use of diabetic shoes and inserts
including nurse practitioners, physician assistants, podiatrists,
clinical nurse specialists, and physicians may order the shoes or
inserts.6 Nurse practitioners are authorized Medicare Part B
providers and provide evidence-based diabetes management
with good outcomes.7 However, to meet Medicare requirements,
a physician must certify the need for diabetic shoes and must
assume management of the patient’s diabetes, which can delay
and sometimes limit access to appropriate care. The American
Association of Nurse Practitioners is promoting legislation to
address the issue.
Diabetic complications involving the foot and ankle result in
significant morbidity, mortality, and health care expenditure. A
multidisciplinary approach has been shown to improve the
quality of foot care and decrease the risk of major amputations.15
As part of foot care teams in both primary and specialty care,
nurse practitioners prevent ulceration, infection, and amputa-
tion by identifying neuropathy, ischemia, deformity, and
impending ulcers early and implementing appropriate treat-
ment. Considering that many foot and ankle complications of
diabetes are preventable with therapeutic footwear, patients
should be able to obtain diabetic shoes when the need is certi-
fied by the nurse practitioner managing their disease, providing
their education, and helping them to navigate the health care
system.
References
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2019.
Jennifer Woody, MSN, FNP-C, is a nurse practitioner in the Department of Or-
thopaedics, School of Medicine, The University of North Carolina, Chapel Hill,
NC. She can be contacted at Jennie_woody@med.unc.edu.
In compliance with national ethical guidelines, the author reports no relationships
with business or industry that would pose a conflict of interest.