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
A Health Care Providers Guide to 

Preventing Diabetes Foot Problems
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

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.
Quality of Care Measure s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

Foot Exam Instru c t i o n s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Visual Foot Inspection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Annual Comprehensive Diabetes Foot Exam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Annual Comprehensive Diabetes Foot Exam Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..1

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 

Statement of Certifying Physician for Therapeutic Footwear. . . . . . . . . . . . . . . . . . . . . . . . . . ..1 

P rescription Form for Therapeutic Footwear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..1 

R E F E R E N C E A N D R E S O U R C E M AT E R I A L S

P revention and Early Intervention for Diabetes Foot Problems: 

A Research Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..2 

R e s o u rce List. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..3 

PAT I E N T E D U C AT IO 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 IO 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) 
2

People who have diabetes are vulnerable to nerve

and vascular damage that can result in loss of protective sensation in the feet, poor circulation, and poor

healing of foot ulcers. All of these conditions contribute to the high amputation rate in people with

diabetes. The absence of nerve and vascular symptoms, however, does not mean that a patient’s feet are

not at risk. Risk of ulceration cannot be assessed without 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 diabetes about preventive health care practices, particularly 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

http://ndep.nih.gov on the Internet.

4

Current clinical recommendations call for a comprehensive foot examination at least once a year for all

people with diabetes to identify high risk foot conditions. People with one or more high risk foot conditions 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 comprehensive 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 pulses, 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 noninsulin-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.
*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.

Annual Comprehensive Foot Exam and

Risk Categorization

Include education for self-care of feet 

and reassess metabolic control.

Low

Risk

Visually Feet

inspect

feet as

warranted 

Visual

inspec

feet a

every v

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
6

Persons at: 

• High risk

• Low risk

(Refer to chart on page 13 for

definitions of risk)

and protective sensation.

• Inspect footwear for blood or other 

d i s c h a rge, abnormal wear patterns, 

f o reign objects, proper fit, appro p r iate 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 management 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 training in foot care .

Visual foot inspection to identify foot 

p roblems. A physician or other trained 

s t a ff should perf o rm the foot inspection.

At every visit

As warranted
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 Associatio

Provider Recognition Program and the National Committee for Quality Assurance) are using some or all 

of the DQIP measures. 

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 

they last had a sensory test, foot inspection, and self-c

education in the past year.

Intermediate-term Impact: A successful program will s

decrease in the incidence of hospital admissions or em

gency room visits for lower extremity infections,

osteomyelitis, and ulcerations.

Long-term Outcomes: A successful program will show 

decrease in the incidence of distal and proximal lowe

extremity amputations.
8

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 1call 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 development 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.
Instructions

Use copies of the annual comprehensive foot exam form to document findings, or incorpo

assessment questions and foot exam into an already existing overall diabetes care plan. A ph

other trained health care provider should conduct the foot exam. Prepare the patient for ex

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 complicatio

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, p

vascular disease or cardiovascular disease are likely to have had diabetes for several years and 

risk for diabetes foot problems. A positive history of a previous amputation places the patien

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. 

son always has an increased risk for developing another foot ulcer, progressive deformity 

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 o

when walking less than one block that is relieved by rest?

This question is to determine whether the patient experiences intermittent claudication w

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.

• D e t e rmine the need for therapeutic foot wear.• Schedule follow-up care and re f e rr a l s .
10

Qpg

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 indication of decreased vascular supply. Loss of sweating function may cause cracking of the skin and fiss 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).
• Indicate any of the foot deformities listed—i.e., toe deformities, bunions, foot drop, pro

metatarsal heads, or Charcot foot. The more serious deformities are illustrated above. P

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 

present or absent.

Hammer Toes Claw Toes

Bunions

(Hallux Valgus)

Plantar View of 

Charcot Joint
12 

• 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.
13 14 

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

p

• Assess/recommend appropriate footwear.

• Provide patient education for preventive self-care

• Perform visual foot inspection at provider’s discre

• 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 susp

• Assess/prescribe appropriate footwear.

• Certify Medicare patients for therapeutic shoe be

• Place a “High Risk Feet” sticker on the medical re

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.
14

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.
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 car

Provide or refer for smoking cessation counseling

Provide patient education about HbA1c or other 

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: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

y 

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____ 

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___

❏ Foot drop

❏ Prominent Metatarsal 

3. Pedal Pulses Fill in the b

“P” or an “A” to indicate p

absent. 

Posterior tibial Left_____ R

Dorsalis pedis Left_____ Ri

❏ 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 shoe

❏ Depth shoes

❏ Primary Care Provider

❏ Diabetes Educator

❏ Podiatrist

❏ RN Foot Specialist 

❏ Pedorthist

❏ Orthotist

❏ Endocrinolog

❏ Vascular Surg

❏ Foot Surgeo

❏ Rehab. Spec

❏ 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

Semmes-Weinstein nylon monofilament and “-” if the patient cannot feel the filament.

Right Foot Left Foot

Notes Notes

18

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 accommodated by a depth shoe.

What the Physician Needs to Do 

1. The certifying physician (the M.D. or D.O.) overseeing the diabetes treatment must review and sign a

“Statement of Certifying Physician for Therapeutic

Shoes” (see form on page 19).

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
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 Footwe

(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 # 

❏ 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

22

National Goals for Diabetes Foot Care

During their lifetime, 1 5 p e rcent 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 remity 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 vented 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 diabetes 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. 

Analysis of a statewide California hospital 

discharge database indicated that in 1991, the ageadjusted 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 experienced 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).
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 diabetes 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 dollars. This cost does not include surgeons’ fees, rehabilitation costs, prostheses, time lost from work, and disability payments (12). Regarding quality of life, a study 

diabetes leading to hospitalization. In 1995, 

ease accounted for 6 percent of hospital dis

listing diabetes and lower extremity ulcers, 

1995 the average hospital stay was 13.7 days

average hospital reimbursement from Medi

a lower-extremity amputation in 1992 was $

and from private insurers it was $26,940. A

same time, rehabilitation was reimbursed at 

of $7,000 to $21,000 (14). 

Prevalence estimates for ulcers in diabete

populations vary. Fifteen percent of all pati

diabetes in a population-based study in sou

Wisconsin experienced ulcers or sores on th

ankle. The prevalence increased with age, e

in patients who were aged 30 or under at d

of diabetes (15). In a large staff-model healt

nance organization, the incidence, outcome

of treatment for foot ulcers were studied ov

in a group of patients with diabetes. In this 

tion, the incidence was nearly 2 percent per 

the direct medical care cost for a 40- to 65-y

male with a new foot ulcer was $27,987 ove

years after diagnosis (16).

After an amputation, the chance of anot

tation of the same extremity or of the oppo

ity within 5 years is as high as 50 percent. T

mortality rate after lower extremity amputa

from 39 to 68 percent (8).
24

factor (1 9). The presence of plantar callus also is highly 

p re d i c t i ve of subsequent ulceration in patients with 

diabetic neuropathy and is more pre d i c t i ve of ulceration than increased plantar foot pre s s u res (2 0). 

Hy p e r g l ycemia is an additional risk factor. In a 1 9 9 6

s t u d y, Finnish re s e a rchers determined risk factors for

amputation in 1 , 0 4 4 middle-aged patients with type 2

diabetes who we re followed for up to 7 years. Be c a u s e

the incidence of amputation was similar in both sexe s

(5 . 6 p e rcent men and 5 . 3 p e rcent women), all statistical

analyses we re carried out combining men and women.

This study found that high fasting plasma glucose leve l s

at baseline, high HbA1c, and the duration of diabetes

we re independently associated with a two-fold risk of

amputation. Signs of peripheral neuro p a t h y, bilateral

absence of vibration sense, and bilateral absence of

Achilles tendon re f l e xes we re two times more fre q u e n t

in patients with amputation than in patients without

amputation (2 1) .

The Diabetes Control and Complications Tr i a l

( D C C T), a ten-year clinical study that concluded in

1 9 9 3, demonstrated that keeping blood glucose levels as

close to normal as possible slows significantly the onset

and pro g ression of eye, kidney, and nerve diseases

caused by diabetes. The study showed that any sustained lowering of the blood glucose helps, even if the

person has a history of poor control (2 2). A follow - u p

study indicated that the reduction in risk for microva scular changes persisted for at least four years after the 

1 5 years than patients randomized to conventional 

therapy (2 4) .

Evidence for a relationship between use of tobacco

and/or alcohol and ulcers or amputation is va r i a b l e

(1 4). Cigarette smoking, howe ve r, is a major risk factor

for microvascular and macrovascular disease and is likely to contribute to diabetes foot disease (2 5). Pe o p l e

with foot and ankle neuropathy are more likely to have

gait abnormalities, postural instability, and sway, and

a re 15 times more likely to suffer some type of injury

during ambulation than those without neuro p a t h y

(2 6 , 2 7 , 2 8 , 2 9 , 3 0) .

The most important risk factors for diabetes foot

p roblems, howe ve r, are peripheral neuropathy and

peripheral vascular disease, as noted by Shaw and

Boulton. T h e re also is a complex interplay betwe e n

these abnormalities and a considerable number of other

c o n t r i b u t o ry factors such as limited mobility, altere d

foot pre s s u res, glycemic control, ethnic backgro u n d ,

and more. The authors stress, howe ve r, that identification of patients at high risk for ulceration is simple and

p re ve n t i ve care should focus on patient education (3 1) .

Causal Pathways for Lower Extremity

Amputations (LEA)

A study of the causal pathways for LEA in patients

with diabetes identified the most common sequences

of events. Seventy-three percent of the amputations 

in study subjects were a result of the causal sequence 
Precipitating or Pivotal Events

In the causal pathway study noted above, foot trauma

was caused by shoe-related re p e t i t i ve pre s s u re leading to

cutaneous ulceration in 3 6 p e rcent of all cases, accidental cuts or wounds in 8 p e rcent, thermal trauma (fro s tbite or burns) in 8 p e rcent, and decubitus ulceration in

8 percent (3 2). Si m i l a r l y, another study found that in

o n e - t h i rd of diabetic amputees with peripheral art e r i a l

disease, the initial lesion was self-induced. The most

common cause of self-injury was ill-fitting new shoes;

the second most common cause was cutting toenails

i m p roperly (3 3). Other investigators identified external

p recipitating factors in 8 4 p e rcent of study patients 

with foot ulcers. The most common factors we re ill 

fitting shoes/socks, acute mechanical trauma, stre s s

u l c e r, and paro n ychia (3 4) .

Identifying Patients at Risk

Tools to Identify High Risk Feet

The importance of identifying individuals at risk for

foot ulceration and LEA and the need for preventive

foot care practices for both the provider and the

patient are significant (35). Identifying patients’ risk

category for foot ulceration helps to determine the 

frequency needed for provider foot examinations, the

level of emphasis on self-care of the feet, and patient

responsibilities (36).

Several simple tools have been developed to identify

people at high risk for ulceration. These tools include a

patient report and a clinical examination to quantify

ament is the Strong Heart Study of 3,638 A

Indians living in Arizona, North and South 

and Oklahoma (39). Use of these measures 

shown to predict subsequent ulceration and 

tion (37). 

In one study, during annual patient exam

researchers recorded the presence of a foot d

history of lower extremity ulceration or am

and the ability to perceive the Semmes-Wei

(10-gram) monofilament at eight sites on th

surface of each foot. Based on the findings, 

were classified as sensate or insensate and p

of four risk categories. Insensitivity to the m

ment occurred in 68 (19 percent) of the pat

screened. Over a 32-month follow-up perio

these patients developed ulcerations and 14 

tions occurred (37).

The recommended number of monofilam

cations needed to assess the risk for ulcerati

One study shows that an 8-site 5.07 (10-gra

monofilament examination (4 sites per foot

completed in 40 seconds and has 90 to 95 p

the sensitivity of a 16-point examination. T

site-per-foot examination specifies two of th

sites – the first and third metatarsal heads. F

other two sites, the authors suggest any toe

metatarsal heads. All sites should be free of 

(40). Another study suggests that reasonabl

and specificity (80 and 86 percent, respectiv

detect patients with an insensate foot can b
26

another person, and patient/provider disagreement

with findings occurred in 12 percent (18) of cases.

Sensory loss, previously undetected by providers, was

found in 16 percent (23) of patients. Self-administered

tests provided patients an opportunity to become more

active team members and resulted in early detection of

insensate feet. The authors caution that self-testing

should not replace regular foot evaluation by a health

care provider (42).

Provider and Patient Education

Education Reduces Lower Extremity

Abnormalities

In a randomized, controlled study, researchers provided intervention patients with foot care education,

behavioral contracts, and telephone and postcard

prompts. The researchers placed foot care prompts on

the medical record, and provided practice guidelines

and flow sheets to clinicians assigned to those patients.

Results showed that primary care physicians in the

intervention group conducted more examinations of

lower extremities, identified those at risk for amputation, and referred more patients for specialized foot

care. Patients in the intervention group received more

patient education, made more changes in appropriate

self-care behaviors, and had fewer short-term foot

problems than patients in the control group (43). 

Ollendorf et al. developed a model to estimate the

economic benefits of amputation prevention strategies

targeted at individuals with a history of foot ulcer over

a period of three years. Estimates were based on an 

plinary care (44). 

Mu l t i d i s c i p l i n a ry team care can be a cost-effective

method for foot screening, pre ve n t i ve care, and tre a tment of active ulcers (4 3 , 4 5 , 4 6). One study of team care

for high risk patients with a history of foot ulcers found

a 2- year foot ulcer incidence rate of 3 0 p e rcent in the

i n t e rvention group compared with 5 8 p e rcent in the

s t a n d a rd treatment gro u p. The team invo l ved physicians, nurses, podiatrists and shoe specialists (4 7) .

A study of 639 patients in a rural primary care clinic

showed significant reductions in lower extremity

amputations. This prospective study of American

Indians with diabetes, compared three consecutive

2- to 3-year time periods:

• a “standard care” period during which patients

received foot care at the discretion of the primary

care provider;

• a “public health” period during which patients were

screened for foot problems and high risk individuals

received foot care education and protective footwear;

• and a “stepped care” period during which comprehensive guidelines for foot management were adapted

to their practice and implemented by a 6-person primary care team. 

The average annual amputation incidence per 1 ,000

diabetic person-years was 29 in the first period, 21 in

the second, and 15 in the third, an overall 48 percent

reduction (48). 
examined 88 patients. The results showed that the 

foot examination was reproducible among primary

care providers and accurate when compared with a

foot care specialist, except in the assessment of foot

deformity and pedal pulses (49). When training

providers to conduct foot exams, particular attention

to these skills may be important.

Components of Effective Self-Management 

Findings from several studies indicate effective components of patient education that contribute to successful patient outcomes. These include giving detailed

foot care recommendations, requesting patient commitment to self-care, demonstrating and practicing

foot care procedures, and communicating a persistent

message that foot complications can be avoided by

self-care. In comparing the effectiveness of intensive

versus conventional education, researchers found that

patients in the intensive group showed greater

improvement in foot care knowledge, better compliance with the recommended foot care routine,

improved satisfaction with foot care, and greater

reduction in the number of foot problems requiring

treatment (5 0 , 5 1). 

Foot care recommendations and demonstrations

should include: washing, drying, and inspecting the

feet; applying an emollient; cutting toenails; treating

minor foot problems; selecting suitable footwear; 

Patients with high risk feet should inspe

twice a day. Those with peripheral neuropa

lar disease, or eye disease should not attemp

their own toenails as this can lead to seriou

inflicted injury.

It is important for a health care provider 

educator to review with the patient all writ

home instructions for self-care of the feet (

program for African Americans, patients re

the most useful parts of a take-home packe

patient instruction booklet, the large hand 

the foot care knowledge self-test with expla

the answers (53).

Researchers found that the frequency of 

care behaviors improved when patients wer

cific instructions stated as precisely as possi

“dry between toes,” “file calluses,” and “nev

foot” rather than more general instructions 

“avoid injury to your feet” (43). Patients sh

be allowed to walk on open plantar ulcers s

tinuous application of mechanical load will 

healing. Walking aids, footwear modificatio

interventions must be used to relieve weigh

Step-by-step guidelines have been publis

providers to conduct patient education wor

foot care including how to attract participa

mote the workshop, develop the agenda, id

appropriate speakers, and conduct a post-w

evaluation (55).
28

Indian Health Se rvice, and the Veterans He a l t h

Administration) and private groups (the American

Diabetes Association Provider Recognition Pro g r a m

and the National Committee for Quality Assurance)

a re using some or all of this set of eight DQIP performance measures. HCFA is responsible for Me d i c a re

and managed care plans that serve Me d i c a re beneficiaries, as well as Medicaid programs. DQIP measures are

likely to increase the frequency of documented annual

foot exams by health care prov i d e r s .

A study of provider practices found that clinicians

were likely to prescribe preventive foot care behaviors

when they were aware of a patient’s high risk for LEA

as evidenced by prior history of foot ulcer. Clinician

awareness of two other major risk factors (peripheral

neuropathy or peripheral vascular disease), however,

did not increase preventive care practices. The study’s

authors concluded that physicians and patients n e e d

periodic reminders to identify patients in all high risk

categories for ulcer or amputation and to schedule visits

for foot care and education in self-care (1 7). To pre ve n t

u n n e c e s s a ry pro g ression of foot problems, pro a c t i ve

communication is recommended between foot care specialists and providers less familiar with diabetes foot

c a re management, as well as timely referral from prim a ry care providers to specialists as necessary (1) .

Self-care Limitations in the Elderly

Barriers to carrying out daily foot care noted by

elderly study subjects included lack of motivation, 

simulated lesions on their toes; over 50 percent of the

older subjects reported difficulty trimming their toe

nails; and only 14 percent had sufficient joint flexibility to allow inspection of the plantar aspect of the foot.

It can be concluded that elderly people who are unable

to perform daily self-care of the feet would benefit

more from regular foot care given by others than from

intensive education (57).

Exercise

In people with diabetes, regular exercise can lower

blood glucose, improve insulin sensitivity, raise HDL

cholesterol, improve blood flow and heart muscle

strength, enhance fibrinolysis, control weight, increase

muscle mass, and provide an overall sense of wellbeing. Because of these effects, regular exercise may

also delay the onset of neuropathy and atherosclerosis.

People who have had type 1 diabetes for more than 10

years, or type 2 diabetes for more than 5 years, should

be screened for medical risk prior to beginning an

exercise program. While the presence of neuropathy

does not rule out exercise, care should be taken not to

worsen soft tissue and joint injury or cause foot ulcers

or bone injury. Stretching muscles before exercise is

important to prevent ligament strain. Swimming or

bicycling are recommended forms of exercise because

they avoid abrasion to the feet (58). Attention to the

construction and fit of footwear is essential.
betes have no indication of lower extremity pain, pressure, or trauma and do not take measures to modify

repetitive pressures. Lack of feeling makes shoe-fitting

assistance essential.

Properly-constructed and well-fitting shoes and shoe

inserts can minimize localized stresses by redistributing

forces during walking. Besides helping patients keep

feet healthy, shoes and orthoses also can help prevent

diabetes complications. Investigators in a recent study

found that after healing of the initial ulcer, re-ulceration occurred after one year in 58 percent of patients

who resumed wearing their own footwear, compared

to 28 percent of those who wore therapeutic footwear

(59). 

Shoe color can contribute to thermal injury of the

insensate foot when shoes are worn in the sun for a

prolonged period (2 to 3 hours). One study showed

that after 30 minutes of exposure to radiant heat, the

mean increase in temperature was between 7.8 and

13.6 degrees Farenheit greater in a black leather walking shoe than in a similar white shoe (60). 

Another study compared the prevalence and severity

of foot deformities and the development of ulceration

in people with diabetes after a great toe amputation.

Due to altered pressure distribution, the foot with

great toe amputation developed more frequent and

more severe deformities of the lesser toes and metatarsophalangeal joints compared to the other intact foot.

Because these patients were at high risk for subsequent

ulceration, the use of special inserts and footwear to

protect the feet was highly recommended (61).

ed will depend on the patient’s foot structu

level, gait, and footwear preference (1).

Shoes should be long enough, and have ro

toe area and over the instep. Shoes with lace

a l l ow adjustment for edema and deformities

ple with early neuropathic changes can wear 

c o m m e rcial footwear such as walking or athl

When used in conjunction with an off-the-s

a c c o m m o d a t i ve insole (plastazo t e / u rethane v

c o m f o rt shoes and athletic footwear we re as 

p rescribed depth shoes in reducing certain m

and great toe pre s s u res (6 2). Some people, h

need the pre s s u re areas redistributed with cu

o rthotics that often re q u i re prescribed depth 

Custom-molded shoes, depth shoes, inse

shoe modifications can be fitted and furnish

podiatrist, orthopedic foot surgeon, orthoti

pedorthist. Depth-inlay shoes provide more 

toe deformities and for the insertion of cust

insoles. Extra-wide shoes provide more room 

bunions and other abnormalities. Rocker so

reduce pressure under metatarsal heads and 

They are particularly useful for reducing th

ulceration in patients with a stiff and rigid 

metatarsal joint (63).

Since 1993, the Medicare footwear benef

special footwear available to more patients t

before. To obtain coverage, patients must h

cian certification that they are at high risk f

tion or amputation, receive a written footw

scription from a podiatrist or other qualifie
30

awareness of the availability of this benefit and how to

obtain reimbursement. 

Conclusion

The staggering human and economic costs of 

diabetes foot disease may be reduced significantly 

with increased practice of several simple preventive

care measures designed to prevent foot ulcers and

lower extremity amputations. Routine annual foot

education about daily selfcare of the feet; use of prop

er footwear; and careful glucose management. National

recommendations and objectives support the application of these practices based on the strong and timetested evidence for the prevention of lower extremity

ulcers and amputations. These national objectives can

serve as a galvanizing call to action for policy makers,

health care providers, and people with diabetes to

make diabetes foot care and prevention a high priority.
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patients with diabetes. New England Jou

Medicine 331(13): 854-60, 1994.

55. Marchand LH, Campbell W, Rolfsen RJ. L

“Feet Can Last a Lifetime”: A public hea

paign. Diabetes Spectrum 9(4): 214-18, 19

56. Diabetes Quality Improvement Project.

(http://www.diabetes.org/dqip.asp)

57. Thompson FJ, Masson EA. Can elderly di

patients co-operate with routine foot ca

and Aging 21:333-7,1992.

58. Ruderman N, Devlin JT, Eds. Health Profe

Guide to Diabetes and Exercise. America

Association, Alexandria, VA 1996.

59. Uccioli L, Faglia E, Monticone G, et al.

Manufactured shoes in the prevention o

foot ulcers. Diabetes Care 18(10): 1376-8, 

60. DeLuca PA, Goforth WP. Effect of shoe co

t e m p e r a t u re and potential solar injury to 

sate foot. Journal of the American Podiat

Association 88(7): 344-8, 1998.
34

Medical Association 87(8): 360-4, 1997.
Connecticut Bioinstruments Inc.

P.O. Box 2567

Danbury, CT 06813

Phone: (800) 336-1935

Single 5.07 (10 gm): $15

Lower Extremity Amputation Prevention

(LEAP) Program

HRSA/BPHC/DPSP

4350 East-West Highway, 9th Floor

Bethesda, MD 20814

Phone: (888) 275-4772

Internet: http://www.bphc.hrsa.gov/leap

Disposable 5.07 (10gm): Free (maximum 50)

(A sample is attached to the pocket card inside this kit)

Medical Monofilament Manufacturing, LLC

116 Long Pond Road

Plymouth, MA 02360

Phone: (508) 746-7877

Internet: http://www.medicalmonofilament.com

Disposable 5.07 (10gm): Prices available upon request

North Coast Medical, Inc.

18305 Sutter Blvd.

Morgan Hill, CA 95037-2845

Phone: (800) 821-9319

Set of six assort. size: $124.95

Single 5.07 (10gm): $24.95

Sensory Testing Systems

1815 Dallas Drive, Suite 11A

Baton Rouge, LA 70806

Phone: (225) 923-1297

Single 5.07 (10gm): $10.00

, 

Prevention, and over 200 organizations

Internet: http://ndep.nih.gov

To order materials, call: (800) 438-5383

Feet Can Last a Lifetime – A Health Care Pro

Guide to Preventing Diabetes Foot Problem

Copies of this kit are available through the 

Diabetes Information Clearinghouse by calli

(800) 438-5383. In addition, the entire text o

may be downloaded from the NDEP website 

http://ndep.nih.gov on the Internet.

Take Care of Your Feet for A Lifetime

This 12-page, easy-to read, illustrated patien

provides step-by-step instructions for prope

It includes a tear-off reminder sheet of foot 

and a patient “To Do” list. Available in Engl

Spanish on the NDEP website at http://ndep

the Internet.

3. National Diabetes Information

Clearinghouse (NDIC) of the Nationa

of Diabetes and Digestive and Kidney Disea

1 Information Way

Bethesda, MD 20892-3560

I n t e rnet: http://www. n i d d k . n i h . g o v / h e a l t h / d i a b 

(301) 654-3327

Foot Care and Diabetes 1993 - Present.

The database from the diabetes subfile of t

Combined Health Information Database (CH

searched for foot care and diabetes informa

citation includes the author, title, source, a 

where to obtain the item, and its price. Form

audiovisuals are provided. CHID is available 

http://chid.nih.gov on the Internet.
36 

, 

Chicago, IL 60603

Internet: http://www.aadenet.org

Phone: (800) TEAM-UP4

(312) 424-2426 for main location

Use the toll-free number to receive the names and

phone numbers of three certified diabetes educators in

the location you specify.

Diabetes Foot and Skin Care

This is one of a series of informative videotapes for

patient education. To order or for a free preview, call

(800) 432-8433.

5. American Diabetes Association

1701 N. Beauregard St.

Alexandria, VA 22311

Internet: http://www.diabetes.org

Phone: (800) 232-6733 for publications

(800) 342-2383 for general diabetes information

(703) 549-1500 – National Office

Information about local activities including materials

also is available by calling your local American Diabetes

Association at 1-888-DIABETES.

Clinical Practice Recommendations

• The American Diabetes Association: Standards of

Medical Care for Patients With Diabetes Mellitus.

Diabetes Care 23 (suppl.1):S32-S42, 2000.

• The American Diabetes Association: Preventive Foot

Care in Patients With Diabetes Mellitus. Diabetes Care

23 (suppl.1):S55-S56, 2000. 

This book for people with diabetes provides information about keeping the feet healthy and preventing

foot complications.

6. American Orthopaedic Foot & 

Ankle Society

1216 Pine Street, Suite 201 

Seattle, WA 98101

Phone: (206) 223-1120 

Fax: (206) 223-1178

E-mail: aofas@aofas.org

Internet: http://www.aofas.org

You may order a copy of any brochure by sending a

self-addressed, stamped envelope to the address above

or download a copy from the internet.

Guidelines for Referral

This journal reprint outlines five criteria for patient

referral to an orthopedist to prevent deterioration or

complications of a diabetic ulcer.

The Diabetic Foot

This patient brochure answers basic questions about

diabetic foot problems and offers information on dayto-day-care to help prevent them.

Patient Brochures

These are short brochures to help patients prevent

injury and care for their feet:

• How to Care for Your Diabetic Feet 

• The Diabetic Foot and Risk: How to Prevent 

Losing Your Leg 

• Shoes and Orthotics for Diabetics 

• Charcot Joints, or Neuropathic Arthropathy 

• Foot Ulcers and the Total Contact Cast
34 

Your Podiatric Physician Talks about Diabetes 

This patient brochure covers preventive foot care,

warning signs, and the role of the podiatric physician

in foot care.

Don’t Let Diabetes Get a Foothold on Your Life

This patient brochure presents an overview of potential

foot problems affecting people with diabetes. It discusses diabetes warning signs, preventive foot care,

and the role of the podiatric physician in the management of diabetes foot problems. 

8. Centers For Disease Control and

Prevention– Division of Diabetes 

Translation Clearinghouse 

P.O. Box 8728

Silver Spring, MD 20910

Internet: http://www.cdc.gov/diabetes

To order, call toll free (877) CDC-DIAB (232-3422)

Take Charge of Your Diabetes

This 76-page spiral-bound book for adults with diabetes focuses on the value of glucose control, team

work, community and family support, and simple preventive steps for helping to promote health and prevent complications (Chapter 9 covers foot care). Yellow

record sheets are provided for recording tests that

should be done once a year and at every visit.

The Economics of Diabetes Mellitus: An Ann

Bibliography 

This bibliography contains most of the impo

nomic studies currently available regarding 

health care costs related to diabetes and int

to reduce the burden of diabetes.

Diabetes Surveillance, 1997

This report documents the number of diabe

hospital discharges with lower extremity am

as a reported procedure between 1990 and 

9. Health Care Financing Administra

To order materials, call the Texas Medical Fo

at (888) 691-9167.

Foot Exam Materials for Academic Detailing

A tool kit for implementing an academic de

intervention for increasing foot exams. The 

includes: an implementation plan for the Pe

Review Organization, guidelines for the det

principles of academic detailing, podiatry co

request and report forms, exam documenta

sheet, chart stickers, references and resourc

a 10-minute video of a foot exam. 

33
38

This compendium includes peer reviewed studies and

quality improvement projects that document successful

interventions in screening, monitoring and treatment

of diabetic patients for improved outcomes. Tables

address barriers to high quality diabetes care and effective interventions. Many of the studies and quality

improvement projects relate specifically to foot care

improvements. Also available at

www.hcfa.gov/quality/3r.htm on the Internet.

Diabetes Interventions Toolkit

This kit provides examples of re s o u rces and tools that

have been used successfully by clinicians, diabetes educators, peer review organizations, managed care org a n i z ations and others to impro v e c a re. It includes flowsheets,

algorithms, patient education materials, practitioner

toolkits and abstraction tools. Many of the tools specifically address foot care. Also available at

h t t p : / / w w w. t a k i n g o n d i a b e t e s . o rg/bestpractices/index 

on the Intern e t .

10. Indian Health Serv i c e

5300 Homestead Road, NE

A l b u q u e rque, NM 87110

I n t e rnet: h t t p : / / w w w.ihs.gov/medical programs/ diabetes

To ord e r, call (505) 248-4182.

S t a n d a rds of Diabetic Foot Care 

This 43-page manual for providers includes minimum

s t a n d a rds for diabetes foot care within the scope of

each IHS facility.

Examining the feet of a person with diabetes; Part 3:

Foot care for all people with diabetes. (Slides are a 

companion piece to “The Basic Approach to the Diabetic

Foot” listed above.)

B o o k l e t s

These illustrated patient booklets, each 10-13 pages, are

written at or below 6th grade level.

• Taking Care of Your Feet 

• Footwear for People with Diabetes

B ro c h u re s

These are short patient information bro c h u re s .

• Take Care of Your Feet

• Numbness to Legs, Hands, and Foot/Pain

• Pain Related to Nerve Damage

Practice Guidelines

Practice guidelines in the form of a decision tree that

a d d resses criteria for diagnosis, risk-factor assessment,

t reatment options, therapeutic targets, monitoring, 

and follow-up. To request a copy contact:

Stephen J. Rith-Najarian M.D. 

Bemidji Area Indian Health Service 

Diabetes Pro g r a m

522 Minnesota Av e n u e

111 Federal Building, Bemidji, MN 56601

E-mail: Srithnajarian@nchs.com.
e ffects of diabetes on feet, special self-care, the pre v e ntion, detection, and proper treatment of foot care pro blems, and the physician’s role in foot examination and

t re a t m e n t .

12. Lower Extremity Amputation

P revention (LEAP) Pro g r a m

H R S A / B P H C / D P S P

4350 East-West Highway, 9th Floor

Bethesda, MD 20814

I n t e rnet: http://www. b p h c . h r s a . g o v / l e a p

To order the LEAP materials listed below, call the BPHC

I n f o rmation Clearinghouse at (888)275-4772 or pre v i e w

and download them from the LEAP website.

F ree Bro c h u re and Monofilament 

Each LEAP monofilament comes with a bro c h u re on how

to perf o rm a sensory foot exam. Single copies are available free to individuals. Clinicians and other health care

o rganizations may obtain up to 50 monofilaments fre e

of charge. Multiple requests from the same org a n i z a t i o n

will not be honored. 

Several versions of the LEAP bro c h u re are available on

the website—in normal and large print and in English

and in Spanish. Other languages will be added. These

b ro c h u res have no copyright restrictions and may be

downloaded and re p ro d u c e d .

Diabetes Foot Screen Form s

Both an abbreviated and a comprehensive foot scre e n

f o rm have no copyright and may be downloaded fro m

the website and re p ro d u c e d .

(888) 275-4772 to order a free VHS copy.

Patient Education Booklet

Designed to go with the patient video, this s

e a s y - t o - read booklet re i n f o rces the importan

p roper foot care for a patient with diabetes 

p rotective sensation. It is illustrated with sim

and can be adapted to include the clinician’s 

n u m b e r. Several translations of this booklet a

on the website.

Video for Clinicians

This 10-minute video, produced by the Texas 

o rganization, is a tool for clinicians and dem

how to perf o rm a comprehensive foot exam

patients with diabetes. This video can be vie

on the website. Free single VHS copies are av

13. Pedorthic Footwear Associati

7150 Columbia Gateway Dr., Suite G

Columbia, MD 21046-1151

Internet: http://www.pedorthics.org

Phone: (800) 673-8447

Diabetes and Pedorthics: Conservative Foot 

This patient brochure provides information 

thics and footwear, including the role that a 

pedorthist plays in preventing and alleviatin

foot complications.

Pedorthics: Foot Care Through Proper Footw

This brochure briefly explains the field of pe

and its practice of designing footwear to ac

serious foot problems.
40

www.cpeds.org on the Internet.

Free Filaments

Monofilaments are available free of charge to the

entire Veterans Health Administration.

Foot Screening Tool

This one-page screening tool documents a foot 

examination and risk status using monofilament 

sensory testing.

• Use a mirror to check the bottoms of your feet

or ask a family member for help if you have

trouble seeing.

3. Wash your feet every day.

• Wash your feet in warm, not hot, water 

every day.

• Dry your feet well. Be sure to dry between 

the toes.

4. Keep the skin soft and smooth.

• Rub a thin coat of skin lotion over the tops and

bottoms of your feet, but not between your toes.

5. Smooth corns and calluses gently.

• If your feet are at low risk for problems, use a

pumice stone to smooth corns and calluses. 

Do n’t use over-the-counter products or sharp

objects on corns or calluses .

6 . If you can see and reach your toenails, trim

them each week or when needed.

• Trim your toenails straight across and file 

the edges with an emery board or nail file.

7. Wear shoes and socks at all times.

• Ne ver walk bare f o o t .

• Wear comfortable shoes that fit well and 

p rotect your feet.

• Feel inside your shoes before putting them on

each time to make sure the lining is smooth 

and there are no objects inside.

9. Keep the blood flowing to your feet.

• Put your feet up when sitting.

• Wiggle your toes and move your ankle

d own for 5 minutes, 2 or 3 times a da

• Do n’t cross your legs for long periods o

• Do n’t smoke.

10. Be more active.

• Plan your physical activity program wi

your doctor.

11. Check with your doctor.

• Have your doctor check your bare fee

out whether you are likely to have seri

problems. Remember that you may no

pain of an injury.

• Call your doctor right away if you fin

sore, blister, or bruise on your foot th

not begin to heal after one day.

• Follow your doctor’s advice about foot 

12. Get started now.

• Begin taking good care of your feet tod

• Set a time eve ry day to check your feet

• Complete the “To Do” list on the back 

page and...

take care of your f

for a lifetime.
❐ Get an emery board and a pumice stone if my doctor

recommends them.

❐ Buy soft, cotton or wool socks. 

❐ Buy a pair of shoes that fit well and cover my feet.

❐ Gi ve away shoes that don’t fit.

❐ Place slippers beside my bed to wear when I get 

out of bed.

❐ Get a mirror to help me see the bottoms of my feet.

❐ Ask for help from a family member or care g i ver if I

c a n’t see my feet.

❐ Keep my next doctor’s appointment.

❐ Ask my doctor if I qualify for special shoes cove red by

Me d i c a re or other insurance plans. 

❐ Ask my doctor or nurse to inspect my feet at 

e ve ry visit.

❐ Plan my physical activity program with my doctor.

❐ Stop smoking.

HIGH RISK HIGH RISK HIGH 

FEET FEET 

HIGH RISK HIGH RISK HIGH 

FEET FEET 

HIGH RISK HIGH RISK HIGH 

FEET FEET 

HIGH RISK HIGH RISK HIGH 

FEET FEET 

HIGH RISK HIGH RISK HIGH 

FEET FEET 

HIGH RISK HIGH RISK HIGH 

FEET FEET 

HIGH RISK HIGH RISK HIGH 

FEET FEET 

HIGH RISK HIGH RISK HIGH 

FEET FEET 
I F YOU HAVE DI A BET E S

Have your doctor check your feet.

take ‘em off!

SHOES

and

SOCKS
Sáqueselos!

SI TI EN E DI A BET E S

Pídale a su médico que le vea los pies.

MEDIAS

y

ZAPATOS
NOVEMBER 2000, NDEP-2

A joint program of the 

National Institutes of Health and

the Centers for Disease 

Control and Prevention

U.S. DEPARTMENT OF HEA

AND HUMAN SERVICES

Public Health Service

National Institutes of Hea

National Institute of Diabetes and

Digestive and Kidney Diseases