The above aphorism could have been written specifically for diabetic foot problems, as many foot lesions are missed because the clinician fails to examine the feet. Paul Brand (1914, 2003) emphasised this when he was asked, at a US Department of Health Conference, to recommend how amputations could be reduced in diabetic patients. Expecting an answer promoting vascular surgery or modern medications, the questioner was surprised at the answer, ‘remove the shoes and socks and examine the feet every time you see a patient with diabetes’.17 The traditional model of disease is that a patient goes to the doctor with symptoms, treatment is then prescribed and the patient recovers.
As this cannot apply to insensate feet, health care professionals have difficulty comprehending the diabetic foot syndrome: they find it difficult to take the initiative and look for early lesions or warning signs of imminent breakdown. Many doctors regard these patients as stupid , how can a sensible individual walk on a swollen red foot with an active ulcer? What we must realise is that an insensitive foot not only is painless, but also does not feel as if it belongs to the individual.17 In screening for ‘at-risk’ feet, it is our job to identify patients at risk of ulceration and help them understand and cope with this health state and thus avoid exposure to environmental hazards that may result in injury (often unperceived) and eventual breakdown.
As with other microvascular complications, there may be no symptoms to suggest to the patient that they have foot problems. The concept of the ‘annual review’ for diabetic patients is now well established.33 Thus, all patients should be screened for retinopathy, hypertension, nephropathy and risk of foot lesions, annually. For the foot, the following are recommended according to the level of care (Table 5.1).