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CLINICAL STATEMENTS AND GUIDELINES

June 11, 2024 Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 e1348

callus formation are precursors of foot ulcers, and patient education regarding foot care has been shown to reduce the occurrence of these lesions.2 Self-foot care consisting of nail and skin care, washing and drying the feet daily, performing foot exercises (eg, heel lifts while standing, ankle pumps, and rolling the bottom of the foot on a tennis ball), as well as protective measures such as protecting the feet from heat or cold, avoiding going barefoot, and wearing socks and appropriately fitting shoes can be beneficial in preventing foot ulcers.1 Visual impairment affects a patient’s ability to perform self-foot care.3 Teaching patients self-examination of the feet with methods such as using a mirror to reflect their own feet and enlisting family members and other support persons in foot care education is important. Resources for patient education for selffoot care have been developed by the American Diabetes Association, US Centers for Disease Control and Prevention, and the National Institute of Diabetes and Digestive and Kidney Disease.18–20 Links for patient education for self-foot care from these organizations are available in the reference section. 2.	 A proactive approach to prevention of foot ulcers

through ongoing foot surveillance and patient self-foot care education is important, particularly among those with risk factors for ulceration (Table 12). In patients with PAD, especially those at highest risk for ulcers, foot inspection at each office visit is important. Shoes and socks are removed for visual inspection of the bare feet. The International Working Group on the Diabetic Foot guidelines propose the frequency of foot inspection (screening examination) depending on risk of ulcers: 1) low risk: annual foot screening; 2) moderate risk: assess feet every 3 to 6 months; and 3) high risk: assess feet every 1 to 3 months.21

3 The presence of foot deformities is a risk factor

for the development of foot ulcers among patients with PAD (Table 12). These deformities, which include bunions (hallux valgus), hammertoe, claw toe, flatfoot (pes planus), severe high-arch foot (pes cavus), Charcot foot, or the arthritic foot, can lead to foot ulcers caused by joint immobility, friction, or pressure. Patients with these types of foot deformities should be referred to a podiatrist for further evaluation and care.8 According to updated guidelines from the International Working Group on the Diabetic Foot, foot deformities place the foot at moderate to high risk for foot ulcer development, and these patients can benefit from a referral to a therapeutic footwear specialist. Appropriate therapeutic footwear can prevent many diabetic foot complications.22 Therapeutic footwear does not always imply a prescription shoe but one that is recommended by a specialist who understands the type or shape of the most protective shoe for the individual that fits properly, reduces plantar pressure, and can help prevent a foot ulcer in patients with diabetes who are at risk.8 Home foot temperature monitoring to identify local increases in skin temperature and areas at risk for ulceration has emerged as another potential tool to reduce the incidence of foot ulcers in high-risk patients, although additional studies are needed.9,23

4 Foot ulcers and amputation caused by PAD or dia-

betic neuropathy are major causes of death and potential mortality in patients with these conditions. Knowledge of and early recognition of the risk factors for foot ulcer development (Table 12) can be used to identify patients at highest risk to implement intervention to prevent foot ulcers and amputations (eg, therapeutic footwear). Thus, a comprehensive foot evaluation, which is a more indepth assessment than the routine foot inspection, is recommended at least annually for patients with PAD (Table 13).6,17,21 This recommendation is based on expert opinion. A 2015 Cochrane database review of 6 studies of complex education-oriented preventive interventions versus usual care of lessintensive education reported insufficient evidence that the education-oriented interventions improved outcomes in terms of foot ulcers and lower extremity amputations, primarily because of heterogeneity of the studies, intervention, and outcomes, and small number of events.7

5 Because of the complexity of PAD, a multispecialty

care team approach promotes collaboration and avoids duplication of care in regard to risk factor management, foot care, and revascularization and allows for coordinated management to improve outcomes for these patients.10–14,24,25 For preventive foot care in particular, the patient and their family or caregivers are important members of this care team. Engagement of foot care specialists (eg, podiatrists) for longitudinal follow-up is recommended by the International Working Group on the Diabetic Foot guidelines for patients at moderate or high risk of foot ulcers and is reasonable for all patients with PAD when available.16 In a study of Medicare claims data, patients with diabetes receiving care from a multispecialty care team that included a foot specialist had reduced rates of lower extremity amputation.15

6 EXERCISE THERAPY FOR PAD

Structured exercise therapy is an important component of care for patients with chronic symptomatic PAD to improve functional status, walking performance,

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