NICE clinical guidelines
Issued: March 2011

Diabetic foot problems: Inpatient management of diabetic foot problems

This is an extract from the guidance. The complete guidance is available at


This guidance has been incorporated into the diabetes NICE Pathway, along with other related guidance and products.


Diabetes is one of the biggest health challenges facing the UK today. In 2010, 2.3 million people in the UK were registered as having diabetes, while the number of people estimated as having either type 1 or type 2 diabetes was 3.1 million. By 2030 it is estimated that more than 4.6 million people will have diabetes (Diabetes UK 2010).

As the longevity of the population increases, the incidence of diabetes-related complications also increases (Anderson and Roukis 2007). Among the complications of diabetes are foot problems, the most common cause of non traumatic limb amputation (Boulton et al. 2005). The feet of people with diabetes can be affected by neuropathy, peripheral arterial disease, foot deformity, infections, ulcers and gangrene.

Diabetic foot problems have a significant financial impact on the NHS through outpatient costs, increased bed occupancy and prolonged stays in hospital. In addition, diabetic foot problems have a significant impact on patients' quality of life; for example, reduced mobility that may lead to loss of employment, depression and damage to or loss of limbs. Diabetic foot problems require urgent attention. A delay in diagnosis and management increases morbidity and mortality and contributes to a higher amputation rate (Reiber et al. 1999).

The common clinical features of diabetic foot problems include infection, osteomyelitis, neuropathy, peripheral arterial disease and Charcot arthropathy.

Laboratory evaluations include blood tests, different imaging techniques, microbiological and histological investigations, but currently there is no guidance on which tests are the most accurate and cost effective.

The primary objective in managing diabetic foot problems is to promote mobilisation. This involves managing both medical and surgical problems and involving a range of medical experts in related fields (Bridges et al. 1994).

Despite the publication of strategies on commissioning specialist services for the management and prevention of diabetic foot problems in hospital ('Putting feet first', Diabetes UK 2009; 'Improving emergency and inpatient care for people with diabetes', Department of Health 2008), there is variation in practice in the inpatient management of diabetic foot problems. This variation is due to a range of factors, including differences in the organisation of care between patients' admission to an acute care setting and discharge. This variability depends on geography, individual trusts, individual specialties (such as whether the service is managed by vascular surgery, general surgery, orthopaedics, diabetologists or general physicians) and the availability of podiatrists with expertise in diabetic foot disease.

This short clinical guideline aims to provide guidance on the key components of inpatient care of people with diabetic foot problems from hospital admission onwards.

Who this guideline is for

This document is intended to be relevant to hospital staff who care for patients with diabetic foot problems.