Initial assessment
The approach to diabetic foot focuses on early identification of factors that increase the risk of ulceration, namely sensorimotor neuropathy, peripheral arterial disease and structural deformities. These mechanisms impair protective sensation, increase plantar pressure and compromise healing, favouring the development of infection, ulceration and amputation. Clinical assessment should be structured and include inspection of the skin and nails, search for fissures, calluses and interdigital fungal infection, as well as structural assessment of deformities such as claw toes, hallux valgus, bony prominences and pes cavus or flatfoot. From a vascular perspective, palpation of the dorsalis pedis and posterior tibial pulses should be performed systematically and completed with ankle–brachial index whenever ischaemia is suspected. Assessment of sensation using a 10 g monofilament and vibration testing helps identify loss of plantar protective sensation.
Warning signs
In the presence of an active ulcer, signs of infection, critical ischaemia, acute Charcot foot or urgent need for debridement, rapid intervention by teams with specific expertise is indicated, given the impact of early management on limb preservation and mortality reduction. These signs should be regarded as a functional emergency, even in the absence of systemic signs.
Risk stratification
After excluding active diabetic foot disease, ulceration risk stratification should be performed. Patients without neuropathy, without deformities and with preserved perfusion are considered low risk and benefit from annual surveillance. Documented sensorimotor neuropathy, with or without structural deformity, defines an intermediate-risk group requiring six-monthly surveillance and possible prescription of insoles or adapted footwear. The presence of peripheral arterial disease, previous ulcer, amputation or consolidated Charcot foot defines high risk, requiring closer follow-up, preferably every one to three months, in a specialist setting.
Therapeutic interventions
In cases of neuropathic ulcer, removal of mechanical load from the affected area is a central element of healing. Off-loading may be achieved with a total contact cast, immobilization boots or customized insoles that redistribute plantar pressure and minimize repeated microtrauma. Glycaemic control, smoking cessation and cardiovascular optimization contribute to improved perfusion, reduced infection and enhanced healing.
Education and self-care
Therapeutic education plays a decisive role. Daily self-inspection of the feet, use of appropriate footwear, skin hydration, professional treatment of calluses and avoidance of walking barefoot significantly reduce the risk of ulceration, readmission and amputation. These measures are particularly important in patients classified as intermediate or high risk, in whom secondary and tertiary prevention has relevant prognostic impact.
Follow-up and surveillance
Surveillance frequency should reflect the degree of risk. Low-risk patients require annual assessment, while intermediate-risk patients should be reassessed every six months. High-risk patients benefit from closer follow-up, every one to three months, with the possibility of multidisciplinary intervention and vascular assessment when indicated. The combination of structured surveillance, metabolic optimization and therapeutic education significantly reduces the incidence of ulceration and amputation in patients with diabetes mellitus.
