The management of diabetic foot

A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine.


Major Recommendations
Definitions of the strength of the recommendations (Grade 1 or 2) and quality of the evidence (Level A–C) are provided at the end of the “Major Recommendations” field.


Prevention of Diabetic Foot Ulcers (DFUs)

1. The committee recommends that patients with diabetes undergo annual interval foot inspections by physicians (MD, DO, DPM) or advanced practice providers with training in foot care (Grade 1C).

2. The committee recommends that foot examination include testing for peripheral neuropathy using the Semmes-Weinstein test (Grade 1B).

3. The committee recommends education of the patients and their families about preventive foot care (Grade 1C).

4a. The committee suggests against the routine use of specialized therapeutic footwear in average-risk diabetic patients (Grade 2C).

4b. The committee recommends using custom therapeutic footwear in high-risk diabetic patients, including those with significant neuropathy, foot deformities, or previous amputation (Grade 1B).

5. The committee suggests adequate glycemic control (hemoglobin A1c <7% with strategies to minimize hypoglycemia) to reduce the incidence of DFUs and infections, with subsequent risk of amputation (Grade 2B).

6. The committee recommends against prophylactic arterial revascularization to prevent DFU (Grade 1C).

Off-Loading DFUs

1. In patients with plantar DFU, the committee recommends offloading with a total contact cast (TCC) or irremovable fixed ankle walking boot (Grade 1B).

2. In patients with DFU requiring frequent dressing changes, the committee suggests off-loading using a removable cast walker as an alternative to TCC and irremovable fixed ankle walking boot (Grade 2C). The committee suggests against using postoperative shoes or standard or customary footwear for off-loading plantar DFUs (Grade 2C).

3. In patients with nonplantar wounds, the committee recommends using any modality that relieves pressure at the site of the ulcer, such as a surgical sandal or heel relief shoe (Grade 1C).

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