Volume 51, Issue 11, November 2022

Preventing diabetes-related foot ulcers through early detection of peripheral neuropathy

Rita McMorrow    Vanessa L Nube    Jo-Anne Manski-Nankervis   
doi: 10.31128/AJGP-06-22-6456   |    Download article
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Peripheral neuropathy, peripheral arterial disease and diabetes-related foot ulcers are the most important risk factors for future amputation. Up to 50% of people with diabetes have distal symmetrical polyneuropathy as a complication of diabetes. Distal symmetrical polyneuropathy results in loss of protective sensation in the feet, increasing the risk of diabetes-related foot ulceration.


The aim of this article is to provide structured guidance for detecting diabetes-related peripheral neuropathy, appropriate referral based on risk assessment and prevention of diabetes‑related foot ulceration.


As a result of the often-asymptomatic nature of diabetes-related peripheral neuropathy, general practice is an ideal location for screening all adults with diabetes for loss of protective sensation. Loss of protective sensation in a person with diabetes indicates an at-risk foot. Increased frequency of foot examination, education in self-care, appropriate footwear and referral to podiatry for non‑ulcerative foot problems can reduce the development of diabetes-related foot ulcers.


Diabetic neuropathy can encompass distal symmetrical polyneuropathy, autonomic neuropathy and other mononeuropathies and polyradiculopathies. This article will focus on diabetes-related distal symmetrical polyneuropathy (DPN) in adults with diabetes.

DPN affects 26–50% of people with diabetes, a third of whom will have painful DPN.1,2 Symptoms, if present, develop peripherally in the feet and toes (reflecting diffuse damage to the longest sensory nerves) and can progress in the classical ‘glove and stocking’ distribution.3 DPN can impair quality of life because of painful symptoms affecting and limiting function, and the associated loss of protective sensation can lead to foot ulceration and amputation.4 DPN often presents in association with other microvascular complications including retinopathy and albuminuria.5 The likelihood of DPN and these other complications increases with the duration of diabetes.6 The trajectory of DPN can be changed by attention to modifiable risk factors, including hyperglycaemia, hypertension and dyslipidaemia.7,8 Optimising glycaemia provides the best protection against the development of DPN, given that it is currently not a reversible condition.9,10

DPN can often progress without symptoms or with symptoms so subtle that DPN goes undetected without testing.11 In people with DPN, the risk of foot ulceration is due to a reduced ability to detect painful stimuli.12–14 Absence of, or reduced, ability to feel an injury from chronic trauma such as ill-fitting footwear or walking on a bony prominence leads to hyperkeratosis, tissue breakdown and ulceration. When protective sensation is lost, burns from heaters or hot water, ingrown or thickened toenails and fungal infections can go undetected and lead to ulceration.15 Once a foot ulcer develops, the future risk of re-ulceration remains high.16 Peripheral arterial disease and foot deformities, such as rigid clawed toes, represent the other two most important risk factors for ulceration.14

Multimorbidity and diabetes-related peripheral neuropathy

Most medical management of type 2 diabetes occurs in primary care, where evidence-based treatment can improve outcomes for people with diabetes.17 Over 90% of people with type 2 diabetes attending general practice in Australia live with multimorbidity.18 People with type 2 diabetes and multimorbidity spend up to 80 hours per month on self-management.19,20 Multimorbidity is also common in people with type 1 diabetes, with an even higher amount of time spent on daily self-management.21,22

People with multimorbidity may prioritise health issues on the basis of their quality of life, such as prioritising analgesia for painful DPN over optimising glycaemia.23 Considering the patient’s preferences is particularly important in multimorbidity, including assessing treatment burden and exploring how a person’s health conditions affect their quality of life. The Problem Areas in Diabetes scale allows for a structured approach to identifying areas of concern related to diabetes management.24 High levels of diabetes distress affect diabetes self-management and glycaemia, essential factors in preventing higher-risk foot disease.25,26 People with multimorbidity visit general practice more frequently than those without multimorbidity.27 This provides opportunities for careful assessment of DPN and other microvascular changes (including annual urine albumin–creatinine ratio and estimated glomerular filtration rate, as well as at least two-yearly assessment for diabetes-related retinopathy) with development of individualised management.

While long-standing diabetes is a risk factor for neuropathy, other factors such as age, alcohol, vitamin B12 deficiency and thyroid disease can co-exist and contribute to peripheral neuropathy (Table 1). Risk of vitamin B12 deficiency when using metformin increases to almost 20% after five years.28 Worsening of peripheral neuropathy in people with type 2 diabetes taking metformin may warrant pathology testing of vitamin B12.  

Table 1. Causes of peripheral neuropathy in people with and those without diabetes
A Alcohol use, autoimmune conditions (eg rheumatoid arthritis, sarcoidosis, systemic lupus erythematosus)
B Vitamin B12/B6 deficiency
C Chronic kidney disease
D Drugs (eg metronidazole; nitrofurantoin; amiodarone; phenytoin; colchicine; chemotherapy agents vincristine, cisplatin and paclitaxel)

Detection of diabetes-related peripheral neuropathy

Up to a fifth of people with type 2 diabetes will have signs of DPN at the time of diagnosis of diabetes.29 DPN is a clinical diagnosis, and the extent and progression of neuropathy needs to be documented. As DPN is frequently asymptomatic, guidelines recommend screening annually for evidence of DPN from diagnosis of type 2 diabetes.11 The National Diabetes Services Scheme has recently released learning modules that can support general practice assessment of foot health.30 Symptoms and relevant examination findings for a targeted diabetes foot screening are summarised in Table 2. A history of foot ulceration, inability to feel a 10 g monofilament or absence of one pedal pulse reliably identify the future risk of foot ulceration.31

Table 2. Symptoms and signs of distal symmetric polyneuropathy11
  • Asymptomatic (50%)
  • Numbness, tingling, poor balance (large myelinated fibres)
  • Pain, burning, electric shocks, stabbing (small myelinated fibres)
Relevant past medical history
  • Previous foot ulceration
  • Lower extremity amputation
  • Peripheral arterial disease or intermittent claudication
  • History of chronic kidney disease
  • Smoking history
Focused examination
  • Inspection: loss of hair, atrophy, ulcer on toes and metatarsals heads, any areas of pressure, callus, superficial infection, fungal nail infections, wasting of intrinsic foot muscles associated with clawing of toes, anhidrosis, skin fissures
  • Vascular status: palpation of pedal pulses; refer to Figures 3 and 4
  • Pressure perception: 10 g monofilament pressure sensation; refer to Figures 1 and 2
  • Vibration perception: 128 Hz tuning fork at the dorsum of the great toe
  • Ankle and knee reflexes
  • Gait assessment
Patient-reported outcome measure to support assessment of diabetic peripheral neuropathy
  • Diabetic neuropathy symptom score41

Monofilament assessment for loss of protective sensation is a crucial component of the physical examination. Current recommendations are for testing three sites on each foot – plantar surfaces of the first and fifth metatarsal heads and the great toe – using a 10 g monofilament until it bends (Figures 1 and 2). Lack of sensation to monofilament at one or two sites suggests a loss of protective sensation.32 Testing at sites with significant callus or active ulceration is not recommended as results are uninterpretable. If monofilament testing is unavailable, testing can be performed using the Ipswich touch test. Testing is performed by lightly touching the plantar surfaces of the first, third and fifth metatarsal heads and great toe; with eyes closed, the person with diabetes indicates when touch is felt.33

Figure 1. Monofilament testing sites

Figure 1. Monofilament testing sites

Figure 2. Monofilament buckling

Figure 2. Monofilament buckling

Figure 3. Dorsalis pedis palpation

Figure 3. Dorsalis pedis palpation

Figure 4. Posterior tibial palpation

Figure 4. Posterior tibial palpation

Bony deformities – such as prominent metatarsal heads, hallux valgus and clawed (or hammer) toes – represent areas of high pressure and potential ulceration in people with DPN. In particular, clawed toes are more common because of the wasted intrinsic foot muscles from motor neuropathy.34 Callus, which occurs in response to chronic pressure over bony areas, is associated with an 11-fold increased risk of ulceration in people with DPN; however, not all areas of deformity will develop a callus.35 It is therefore recommended that foot deformity and other non-ulcerative pathology be identified in foot examination as they contribute to foot ulcer risk, particularly in the presence of DPN. The International Working Group on the Diabetic Foot (IWGDF) Risk Stratification System, outlined in Table 3, is based on history and physical examination findings.36 According to the IWGDF Risk Stratification System, anyone at moderate to high risk requires a referral to a podiatrist. For people with diabetes and any foot pathology, such as callus, ingrown or thickened toenails and fungal infections, podiatry consultation is recommended to prevent foot ulcers.37 Symptoms of peripheral arterial disease (eg calf muscle pain on exertion) or signs including absent or weak foot pulses in an adult with diabetes warrant referral for non-invasive vascular testing.

Table 3. The International Working Group on the Diabetic Foot (IWGDF) Risk Stratification System and corresponding foot screening and examination frequency36
IWGDF category Ulcer risk Risk factors Re-screen and referrals
0 Very low No loss of protective sensation and no peripheral artery disease Screen annually
1 Low Loss of protective sensation or peripheral artery disease Re-screen every 6–12 months
2 Moderate Loss of protective sensation and peripheral artery disease
Loss of protective sensation and foot deformity
Peripheral artery disease and foot deformity
Re-screen every 3–6 months
Podiatry review within 6–8 weeks
3 High Loss of protective sensation or foot deformity and one of:
  • history of a foot ulcer
  • lower limb amputation
  • end-stage renal disease
Re-screen every 1–3 months
Podiatry review within 2–4 weeks

Access to podiatry consultation in Australia can be facilitated through Medicare Benefits Schedule chronic disease programs, My Aged Care for people with diabetes aged over 65 years (or over 50 years for Aboriginal and Torres Strait Islander people) or state-funded podiatry services (hospital outpatient clinics and community health services). The latter will prioritise people at moderate and high risk of foot ulceration, and including the risk stratification assessment can facilitate appropriate triage of referrals in these services. For people with active foot ulcers and acute Charcot neuroarthropathy, two major complications associated with DPN, specialist interdisciplinary team-based care is via High Risk Foot Services.

Charcot neuroarthropathy is characterised by fracture and dislocation, which may occur in DPN or other advanced neuropathies, most typically in the foot or ankle. It presents as a unilateral, warm and swollen foot that is painless (or relatively so). It may or may not be preceded by an injury or event such as surgery or prolonged infection.38 An injury is often not reported, potentially due to loss of sensation. Charcot neuroarthropathy can mimic more common conditions such as cellulitis, soft tissue injury, gout or deep vein thrombosis. If Charcot neuroarthropathy is suspected, it is recommended the person with diabetes minimise weight-bearing immediately and be referred to a local High Risk Foot Service or clinician with expertise in assessing and managing the condition. Successful treatment relies on prompt diagnosis and management in a total contact cast for several months until the inflammation subsides and fractures (if present) heal.39

Practical strategies for preventing foot ulcers and amputation

For people with DPN, minor traumas related to ill-fitting shoes can precede ulceration of the foot, as shown in the case in Box 1. International guidelines have recently been adapted to the Australian context and allow a general practice to make evidence-based recommendations and education as part of diabetes care.40 Resources for patient education and referrals are listed in Table 4.

Box 1. Case study
John, aged 57 years, is a man who was diagnosed with type 2 diabetes early in the COVID-19 pandemic. He takes metformin 2 g daily, gliclazide 60 mg daily and dulaglutide 1.5mg weekly. During the COVID-19 pandemic, his diabetes review appointments were via telehealth. John cut his toenails at home, and soon after, he felt a mild burning sensation in his left great toe at night when he took off his pull-on steel-cap boots. On examination, the left great toenail was ingrown, with 1.5 cm of erythema and swelling with purulent discharge. Pedal pulses were palpable bilaterally, and 10 g monofilament pressure sensation was reduced at the left great toe and first metatarsal head. The infection was treated with oral antibiotics, and the ingrown toenail was removed. John was referred for community-based podiatry and changed to lace-up steel-cap boots to help minimise trauma.

Table 4. Practical resources
National Diabetes Services Scheme – Foot Forward modules
National Diabetes Services Scheme – Diabetes and feet: A practical toolkit for health professionals using the Australian diabetes-related foot disease guidelines
Diabetes Foot Risk Stratification and Triage
National Diabetes Services Scheme – Fact sheet: Looking after your feet (patient resource)
Commonwealth My Aged Care scheme Online at or phone 1800 200 422
Directory of High Risk Foot Service

For people with DPN, the first step is for people and their families to understand that their foot sensation is reduced. Collaborating with the person with diabetes to develop a foot action plan includes structured foot care education and footwear review. Initial discussion in general practice (while awaiting podiatry review) for people at moderate and high risk can include safety regarding footwear, avoidance of thermal injury and how to check their feet to prevent complications. Essential discussion includes the importance of foot protection by not walking barefoot or in socks without shoes, indoors or outdoors. People with diabetes should cut toenails straight across. If there is an increase in weight-bearing activity, people with diabetes should be encouraged to wear appropriate footwear and increase self-monitoring for any signs of injury. All people with diabetes and loss of protective sensation or peripheral arterial disease are encouraged to perform a daily inspection of their feet, careful drying of feet between toes and application of topical emollients to prevent skin from drying. People with DPN and their families must understand that foot problems can occur without pain and that they should seek treatment promptly for any foot problem.


All adults with diabetes require annual foot screening to assess for loss of protective sensation. Loss of protective sensation in a person with diabetes indicates an at-risk foot. General practitioners can reduce the development of diabetes-related foot ulcers through increased foot screening, foot self-care education, safe and appropriate footwear and timely referral to podiatry for non-ulcerative foot problems.

Competing interests: RM reports an Australian Rotary Health PhD Scholarship. VLN is a Committee Member on the Scientific Committee for the Advanced Practicing Podiatry Group – High Risk Foot and Lower Extremity Amputation Prevention Conference 2022. JM reports payments from Medical Research Future Fund, Paul Ramsay Foundation and ACADI Diabetes Centre.
Provenance and peer review: Commissioned, externally peer reviewed.
Funding: None.
Correspondence to:
The authors would like to thank the Podiatry Department, Royal Prince Alfred Hospital, and the Diabetes Centre High Risk Foot Service, Royal Prince Alfred Hospital, for the images.
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  1. Dyck PJ, Kratz KM, Karnes JL, et al. The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: The Rochester Diabetic Neuropathy Study. Neurology 1993;43(4):817–24. doi: 10.1212/wnl.43.4.817. Search PubMed
  2. Abbott CA, Malik RA, van Ross ER, Kulkarni J, Boulton AJ. Prevalence and characteristics of painful diabetic neuropathy in a large community-based diabetic population in the UK. Diabetes Care 2011;34(10):2220–24. doi: 10.2337/dc11-1108. Search PubMed
  3. Feldman EL, Callaghan BC, Pop-Busui R, et al. Diabetic neuropathy. Nat Rev Dis Primers 2019;5(1):41. doi: 10.1038/s41572-019-0092-1. Search PubMed
  4. Van Acker K, Bouhassira D, De Bacquer D, et al. Prevalence and impact on quality of life of peripheral neuropathy with or without neuropathic pain in type 1 and type 2 diabetic patients attending hospital outpatients clinics. Diabetes Metab 2009;35(3):206–13. doi: 10.1016/j.diabet.2008.11.004. Search PubMed
  5. Dyck PJ, Davies JL, Wilson DM, Service FJ, Melton LJ 3rd, O’Brien PC. Risk factors for severity of diabetic polyneuropathy: Intensive longitudinal assessment of the Rochester Diabetic Neuropathy Study cohort. Diabetes Care 1999;22(9):1479–86. doi: 10.2337/diacare.22.9.1479. Search PubMed
  6. Tapp RJ, Shaw JE, de Courten MP, Dunstan DW, Welborn TA, Zimmet PZ; AusDiab Study Group. Foot complications in Type 2 diabetes: An Australian population-based study. Diabet Med 2003;20(2):105–13. doi: 10.1046/j.1464-5491.2003.00881.x. Search PubMed
  7. Tesfaye S, Chaturvedi N, Eaton SE, et al; EURODIAB Prospective Complications Study Group. Vascular risk factors and diabetic neuropathy. N Engl J Med 2005;352(4):341–50. doi: 10.1056/NEJMoa032782. Search PubMed
  8. Braffett BH, Gubitosi-Klug RA, Albers JW, et al; DCCT/EDIC Research Group. Risk Factors for Diabetic Peripheral Neuropathy and Cardiovascular Autonomic Neuropathy in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study. Diabetes 2020;69(5):1000–10. doi: 10.2337/db19-1046. Search PubMed
  9. Ang L, Jaiswal M, Martin C, Pop-Busui R. Glucose control and diabetic neuropathy: Lessons from recent large clinical trials. Curr Diab Rep 2014;14(9):528. doi: 10.1007/s11892-014-0528-7. Search PubMed
  10. Ismail-Beigi F, Craven T, Banerji MA, et al; ACCORD trial group. Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: An analysis of the ACCORD randomised trial. Lancet 2010;376(9739):419–30. doi: 10.1016/S0140-6736(10)60576-4. Search PubMed
  11. Pop-Busui R, Boulton AJ, Feldman EL, et al. Diabetic neuropathy: A position statement by the American Diabetes Association. Diabetes Care 2017;40(1):136–54. doi: 10.2337/dc16-2042. Search PubMed
  12. Abbott CA, Carrington AL, Ashe H, et al; North-West Diabetes Foot Care Study. The North-West Diabetes Foot Care Study: Incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med 2002;19(5):377–84. doi: 10.1046/j.1464-5491.2002.00698.x. Search PubMed
  13. Leese GP, Cochrane L, Mackie AD, Stang D, Brown K, Green V. Measuring the accuracy of different ways to identify the ‘at-risk’ foot in routine clinical practice. Diabet Med 2011;28(6):747–54. doi: 10.1111/j.1464-5491.2011.03297.x. Search PubMed
  14. Monteiro-Soares M, Boyko EJ, Ribeiro J, Ribeiro I, Dinis-Ribeiro M. Predictive factors for diabetic foot ulceration: A systematic review. Diabetes Metab Res Rev 2012;28(7):574–600. doi: 10.1002/dmrr.2319. Search PubMed
  15. Boyko EJ, Ahroni JH, Cohen V, Nelson KM, Heagerty PJ. Prediction of diabetic foot ulcer occurrence using commonly available clinical information: The Seattle Diabetic Foot Study. Diabetes Care 2006;29(6):1202–07. doi: 10.2337/dc05-2031. Search PubMed
  16. Davis WA, Norman PE, Bruce DG, Davis TM. Predictors, consequences and costs of diabetes-related lower extremity amputation complicating type 2 diabetes: The Fremantle Diabetes Study. Diabetologia 2006;49(11):2634–41. doi: 10.1007/s00125-006-0431-0. Search PubMed
  17. Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008;358(6):580–91. doi: 10.1056/NEJMoa0706245. Search PubMed
  18. Chiang JI, Furler J, Mair F, et al. Associations between multimorbidity and glycaemia (HbA1c) in people with type 2 diabetes: Cross-sectional study in Australian general practice. BMJ Open 2020;10(11):e039625. doi: 10.1136/bmjopen-2020-039625. Search PubMed
  19. Jowsey T, McRae IS, Valderas JM, et al. Time’s up. Descriptive epidemiology of multi-morbidity and time spent on health related activity by older Australians: A time use survey. PLoS One 2013;8(4):e59379. doi: 10.1371/journal.pone.0059379. Search PubMed
  20. Unruh KT, Pratt W. The invisible work of being a patient and implications for health care: ‘[the doctor is] my business partner in the most important business in my life, staying alive’. Conf Proc Ethnogr Prax Ind Conf 2008;2008(1):40–50. doi: 10.1111/j.1559-8918.2008.tb00093.x. Search PubMed
  21. Shubrook JH, Brannan GD, Wapner A, Klein G, Schwartz FL. Time needed for diabetes self-care: Nationwide survey of certified diabetes educators. Diabetes Spectr 2018;31(3):267–71. doi: 10.2337/ds17-0077. Search PubMed
  22. van den Boom L, Buchal G, Kaiser M, Kostev K. Multimorbidity among adult outpatients with type 1 diabetes in Germany. J Diabetes Sci Technol 2022;16(1):152–60. doi: 10.1177/1932296820965261. Search PubMed
  23. Sathanapally H, Sidhu M, Fahami R, et al. Priorities of patients with multimorbidity and of clinicians regarding treatment and health outcomes: A systematic mixed studies review. BMJ Open 2020;10(2):e033445. doi: 10.1136/bmjopen-2019-033445. Search PubMed
  24. Polonsky WH, Anderson BJ, Lohrer PA, et al. Assessment of diabetes-related distress. Diabetes Care 1995;18(6):754–60. doi: 10.2337/diacare.18.6.754. Search PubMed
  25. Nanayakkara N, Pease A, Ranasinha S, et al. Depression and diabetes distress in adults with type 2 diabetes: Results from the Australian National Diabetes Audit (ANDA) 2016. Sci Rep 2018;8(1):7846. doi: 10.1038/s41598-018-26138-5. Search PubMed
  26. Fisher L, Glasgow RE, Strycker LA. The relationship between diabetes distress and clinical depression with glycemic control among patients with type 2 diabetes. Diabetes Care 2010;33(5):1034–36. doi: 10.2337/dc09-2175. Search PubMed
  27. Glynn LG, Valderas JM, Healy P, et al. The prevalence of multimorbidity in primary care and its effect on health care utilization and cost. Fam Pract 2011;28(5):516–23. doi: 10.1093/fampra/cmr013. Search PubMed
  28. Aroda VR, Edelstein SL, Goldberg RB, et al; Diabetes Prevention Program Research Group. Long-term metformin use and vitamin B12 deficiency in the diabetes prevention program outcomes study. J Clin Endocrinol Metab 2016;101(4):1754–61. doi: 10.1210/jc.2015-3754. Search PubMed
  29. Bonora E, Trombetta M, Dauriz M, et al. Chronic complications in patients with newly diagnosed type 2 diabetes: Prevalence and related metabolic and clinical features: The Verona Newly Diagnosed Type 2 Diabetes Study (VNDS) 9. BMJ Open Diabetes Res Care 2020;8(1):e001549. doi: 10.1136/bmjdrc-2020-001549. Search PubMed
  30. Diabetes Australia. National Diabetes Services Scheme. FootForward for diabetes 2022. Turner, ACT: Diabetes Australia, 2022. Available at Search PubMed
  31. [Accessed 29 September 2022]. Search PubMed
  32. Crawford F, Cezard G, Chappell FM, et al. A systematic review and individual patient data meta-analysis of prognostic factors for foot ulceration in people with diabetes: The international research collaboration for the prediction of diabetic foot ulcerations (PODUS). Health Technol Assess 2015;19(57):1–210. doi: 10.3310/hta19570. Search PubMed
  33. Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Hinchliffe RJ, Lipsky BA; IWGDF Editorial Board. Practical guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update). Diabetes Metab Res Rev 2020;36 Suppl 1:e3266. doi: 10.1002/dmrr.3266. Search PubMed
  34. Rayman G, Vas PR, Baker N, et al. The Ipswich Touch Test: A simple and novel method to identify inpatients with diabetes at risk of foot ulceration. Diabetes Care 2011;34(7):1517–18. doi: 10.2337/dc11-0156. Search PubMed
  35. Cowley MS, Boyko EJ, Shofer JB, Ahroni JH, Ledoux WR. Foot ulcer risk and location in relation to prospective clinical assessment of foot shape and mobility among persons with diabetes. Diabetes Res Clin Pract 2008;82(2):226–32. doi: 10.1016/j.diabres.2008.07.025. Search PubMed
  36. Murray HJ, Young MJ, Hollis S, Boulton AJ. The association between callus formation, high pressures and neuropathy in diabetic foot ulceration. Diabet Med 1996;13(11):979–82. doi: 10.1002/(SICI)1096-9136(199611)13:11<979::AID-DIA267>3.0.CO;2-A. Search PubMed
  37. Bus SA, Lavery LA, Monteiro-Soares M, et al; International Working Group on the Diabetic Foot. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020;36 Suppl 1:e3269. doi: 10.1002/dmrr.3269. Search PubMed
  38. Bus SA, Armstrong DG, van Deursen RW, Lewis JE, Caravaggi CF, Cavanagh PR; International Working Group on the Diabetic Foot. IWGDF guidance on footwear and offloading interventions to prevent and heal foot ulcers in patients with diabetes. Diabetes Metab Res Rev 2016;32 Suppl 1:25–36. doi: 10.1002/dmrr.2697. Search PubMed
  39. Game FL, Catlow R, Jones GR, et al. Audit of acute Charcot’s disease in the UK: The CDUK study. Diabetologia 2012;55(1):32–35. doi: 10.1007/s00125-011-2354-7. Search PubMed
  40. Petrova NL, Edmonds ME. Acute Charcot neuro-osteoarthropathy. Diabetes Metab Res Rev 2016;32 Suppl 1:281–86. doi: 10.1002/dmrr.2734. Search PubMed
  41. Lazzarini PA, Raspovic A, Prentice J, et al; Australian Diabetes-related Foot Disease Guidelines & Pathways Project. Guidelines development protocol and findings: Part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. J Foot Ankle Res 2022;15(1):28. doi: 10.1186/s13047-022-00533-8. Search PubMed
  42. Meijer JW, Smit AJ, Sonderen EV, Groothoff JW, Eisma WH, Links TP. Symptom scoring systems to diagnose distal polyneuropathy in diabetes: The Diabetic Neuropathy Symptom score. Diabet Med 2002;19(11):962–65. doi: 10.1046/j.1464-5491.2002.00819.x. Search PubMed

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