Prevention of complications through a community based screening programme to identify patients at risk of ulceration is the cornerstone of a diabetic foot management programme. All patients are taught about the risks and about basic care of their feet. The Cochrane database systematic review by Valk et al (2001) concluded that education may reduce ulceration and amputations, although the effect was greatest in high-risk patients and in the short term (one-year follow-up). Podiatric checking and care are provided as indicated by risk category. Patients at high risk of ulceration also have accommodative shoes and pressure-relieving insoles provided. Even patients at low risk of adverse events should probably receive some education about self-care and surveillance and the importance of contacting helth professionals if problems arise (McIness 2011).
Screening, education and good metabolic care can reduce the incidence of neuropathy and ulceration. In patients at high risk, appropriate shoewear and insoles can delay ulceration (and re-ulceration after ulcer healing) (McLaughlin et al 2004). This group of patients are at high risk of death from cardiovascular and renal disease, and treatment of hypertension and hyperlipidaemia is important (Firestone 2010, Brownrigg 2012).
Prophylactic correction of hammertoes to prevent ulceration in 31 neuropathic diabetics was described by Armstrong et al (1996). 2/14 with previous ulceration developed wound infections and 1/14 a recurrent ulcer. No ulcers or infections occurred in the other 17. Without a RCT standardised for risk it is difficult to interpret this study and those noted below.
Frigg (2007) carried out deformity correction to prevent ulcer recurrence or aid ulcer healing in 14 patients. No ulcers recurred.
Dellon (1992, 2004) considers that diabetic neuropathy is principally due to entrapment of swollen nerves and has described techniques for decompressing the common peroneal, tibial and deep peroneal nerves. Aszmann (2004) described 50 diabetic patients who underwent prophylactic nerve decompression. In the treated limbs there were no ulcers at 2-7y follow-up, while 12 ulcers and 3 amputations occured in the contra-lateral untreated limbs.