Professional Care: A visit, at least annually to a foot care professional for a comprehensive exam--and to perform focused interventions such as nail care or the paring of calluses, is indicated for the asymptomatic patient who doesn’t have a high risk foot (i.e. still has protective sensation, no foot deformities). For those at high risk for ulceration (i.e. history of previous ulcer or amputation, presence of foot deformities or they are experiencing a loss of protective sensation) professional care visits will need to be more frequent.

Protective Footwear:  Many foot ulcers are caused by poorly fitting shoes and socks. It is important to question the patient about their footwear worn in the workplace, on special occasions and inside the home. Medicare will pay for one pair of extra depth shoes and 3 pairs of inserts annually, or one pair of custom molded shoes per year. They might not be perceived as very glamorous but they can save your patients toes and feet. Patients should shop for shoes later in the day, when the foot may be more swollen and should look for an over-the-counter shoe with a high toe box (New Balance athletic shoes are particularly good in this regard).

Pressure Reduction: in addition to selecting footwear that avoids putting pressure over any bony deformities, associated with motor neuropathic changes (i.e. claw and hammer toes), pressure reduction may also be facilitated through the use of cushioned insoles, custom orthotics and padded socks.

Prophylactic surgery to correct structural deformities such as bunions or hammer toes or metatarsal head resection may be useful in decreasing pressure to a vulnerable area and thereby reducing the risk for ulceration.

Patient education: the patient or their caregiver needs to be taught how to perform daily foot self-care and foot inspection. Daily assessment of the feet and lower extremities is essential for early detection and prompt intervention of potential problems. The patient must also be instructed on the importance of controlling their blood sugars, following their diet, regular exercise, and medication prescriptions.

At a minimum, the patient or their caregiver should do the following: look and feel feet every day (using a mirror to see the bottom of the foot can be helpful). Look for changes in temperature, breaks in the skin and for reddened or darker areas. Areas that are especially susceptible are those found between the toes. Patients should be instructed to contact their health care provider the minute they see any thing unusual. They should not try to treat this on their own. They should also be instructed to wash their feet every day—and not to check the temperature of bath water using their feet—nor should they soak their feet. Instruct them to dry their feet thoroughly--especially the areas between the toes. Teach them to apply a thin coat of fragrance free lotion to the foot and heel area and instruct them not to apply between the toes. For those patients who have protective sensation, they may trim their own toenails by cutting straight across and never down into the sides. They may also be taught to gently buff their corns and calluses with a pumice stone after they have washed their feet. For those patients who have lost protective sensation, have peripheral arterial disease or other factors limiting their self-care abilities, they should receive their nail care from a foot care professional. Instruct patients to wear socks and shoes at all times and to never walk barefoot--even inside their own home. An stress that it is important they always feel inside their shoes before putting them on. Teach them to avoid crossing their legs when sitting and to elevate them, unless there is significant pain due to peripheral arterial disease when doing this. And be sure to instruct the patient on smoking cessation strategies, if applicable.