Foot ulcers and other foot problems are one of the commonest causes of morbidity (disability), and even mortality (high death rate), amongst the diabetics in our country.
	Diabetics account for the second largest group of people undergoing lower limb amputations (after accidents) in our country.
	Foot problems are also the reason for repeated hospital admissions and prolonged indoor stay.
	The frequency and the severity of foot problems can be decreased with adequate foot evaluation and, as importantly, patient education about foot care
	All patients at the time of diagnosis and annually, must undergo a comprehensive foot evaluation which includes a complete vascular, neurological, musculo-skeletal, skin and soft tissue examination.
	This comprehensive evaluation does not necessarily involve the use of sophisticated, complex and costly equipment; the use of a simple point based protocol ( given below) allows delineation of most people at high, or increasing, risk for the development of foot problems; some patients may require more sophisticated evaluation.
	Patients at high, or increasing, risk may require more frequent evaluations and proactive management.

	Patients who walk barefoot.
	Patients with diabetic neuropathy. (nerve damage)
	Patients with significant diabetic peripheral vascular disease. (damage to vessels supplying the limbs).
	Patients who smoke or use tobacco in any form.
	Those with a foot deformity.
	Diabetics with a history of previous ulcers or foot infections.
	Patients with abnormal gait. (walk in unbalanced manner).
	Those with significant skin and nail infections or deformities.
	Blind/partially sighted persons. (increase chances of repeated injuries to foot)
	Elderly patients; especially those living alone.
	Diabetics with chronic renal failure. (kidney failure).
	Patients with high alcohol intake.

	For evidence of dry, or excessively moist, skin, hair and nail abnormalities corns, calluses and infection
	For presence of deformities, heel spurs, flat arches, etc.

   Sensation

Inquire for symptoms (numbness in the periphery, etc.)

Large nerve fiber function.

Vascular.

	Inquire for symptoms of intermittent claudication (pain limbs while walking a fixed distance, which can disappear after walking further-due to damaged blood vessels)
	Palpation of pedal pulses. (pulses of feet)
	Brachial to ankle systolic pressure ratio.
	If foot pulses are absent examine proximal pulses (popliteal and femoral)

  If necessary, the following tests should be considered :

1. Doppler studies for blood flow.

2. Arteriography.

All these investigations may not be necessary in every patient and the range of investigations should be individualized.

The routine use of a simple point based protocol allows delineation of patients with high, or increasing risk, for the development of foot problems.

Simple protocol for judging potential for foot problems
(Basic Point Based Protocol)
Paraesthesia (increased sensations )	no (0)	yes (2)
Hypoesthesia (decreased sensations)	no (0)	yes (4)
Anesthesia	no (0)	yes (6)
Veins on dorsum of foot
Empties normally on lying flat  Distended on lying flat  Distended on leg elevation to 45	(0)+  (3)  (6)

H/O intermittent claudication	no (0)	moderate (3)	severe (6)
H/O rest pain	no (0)	moderate (3)	severe (6)
H/O nocturnal leg pain	no (0)	moderate (3)	severe (6)
Peripheral pulses	normal (0)	feeble (4)	absent (6)
Filling time after blanching of nail beds By pinching (in seconds)	< 5(0)	5-10(1)	11-15(2)	>15(4)

Skin and Nail Changes:
Skin: cold/dry/thickened/atrophic/shining/loss of hair	no(0)	yes(2)
Nails: thickened/ingrown/ fungal infections	no(0)	yes(2)
Presence of corns	no(0)	yes(2)
Presence of calluses	no(0)	yes(2)

	Foot problems can develop quickly in people with diabetes because of poor circulation, hardening of the arteries, or nerve damage.
	Poor circulation can lead to symptoms such as cold feet, leg cramps, shiny or dry skin, loss of hair, and slow healing.
	Nerve damage can cause pain, numbness, loss of feeling, burning, and tingling in the legs or feet.
	If you have nerve damage and poor circulation, you are vulnerable to even more serious complications. You may not be able to feel a small cut or blister on your foot. If the cut or blister becomes infected, this can lead to a more serious infection called gangrene.
	If gangrene is not treated soon enough, a section of the foot may need to be amputated to save the rest of the foot or leg.
	Your feet will be more prone to dryness, peeling, and cracking, so always keep them clean and dry.
	After bathing, dry your feet carefully, especially between the toes, and apply a thin coating of baby oil or lotion.
	Do not put baby oil or lotion between your toes.
	Similar complications can develop from ingrown toenails, plantar warts, and puncture wounds.