In many Western centers, diabetic patients with foot ulcers are managed in specialist foot clinics run by a multidisciplinary foot team (MDFT). This may include a combination of diabetes physicians, specialist nurses, podiatrists, vascular surgeons, orthopedic surgeons, orthotists, or psychologists. Patients with new ulcerations, swelling, or discoloration should be referred to these services promptly from primary care for urgent assessment and management. In the presence of severe infection, they may require prompt hospitalization for intravenous antibiotics. Evidence supports the role of the MDFT with one study finding that the total number of amputations fell by 70 % over 11 years following improvements in foot care services and implementation of an MDFT. [20]. The National Institute for Healthcare and Care Excellence (NICE) recommends that hospitals should have a care pathway for patients with diabetic foot problems, which should be managed by an MDFT, consisting of healthcare professionals with specialist skills and competencies [21].

Diagnosis of infection in diabetic foot ulcers can be difficult as signs one would expect to find locally (pain, erythema, swelling, and raised temperature) may not be present [8]. Systemic signs may only be present in severe infections such as osteomyelitis or septicemia. Infection in a diabetic foot wound can produce signs such as poor blood glucose control, increased slough/exudate, pus, foul smell or change in smell, pain, and warmth. Although diagnosing infection at an early stage can be challenging, it is crucial in preventing progression of the infection and thereby preventing necrosis, gangrene, and amputation [22]. More than half of all diabetic foot ulcers will become infected at sometime so a high index of suspicion is vital [23]. The following factors increase the likelihood of an infection developing [24]: a positive probe-to-bone test, ulcer present for more than 30 days, a history of recurrent DFUs, a traumatic foot wound, the presence of peripheral arterial disease in the affected limb, a previous lower-extremity amputation, loss of protective sensation, the presence of renal insufficiency, and a history of walking barefoot.

Signs of severe infections include widespread inflammation, crepitus, bullae, necrosis, or gangrene. If a wound appears infected, appropriate cultures should be sent (soft tissue, secretions, or bone if osteomyelitis is suspected). All open wounds will be colonized with pathogens so superficial swabs are unlikely to culture the specific pathogen responsible for the infection. Empirical antibiotics should be prescribed in accordance with local microbiology advice while awaiting culture results and sensitivities. Other useful investigations include a full blood count, C reactive protein, renal function and liver function. Evidence does not support antibiotic therapy for ulcers that do not appear infected. Topical antibiotics may be useful in cases where there is poor vascular supply leading to reduced antibiotic tissue penetration, but the evidence base supporting their use is thin.

Diabetic patients with signs of infected ulceration should have a radiograph of their foot to detect any evidence of osteomyelitis. Signs of osteomyelitis on a radiograph include focal destruction of cortical bone, periosteal new bone formation, soft tissue swelling secondary to inflammation around the area, and focal osteoporosis caused by hyperemia. Conventional radiographs may not display any signs of osteomyelitis for up to 10 days so other types of imaging such as MRI should be used, where available, if clinical suspicion remains despite a normal radiograph [25]. If MRI is contraindicated or unavailable, a labeled leukocyte imaging scan can be performed instead. Radiography can also be used to exclude a foreign body in tissues which is common with plantar neuropathic ulcers.

As described previously, deformities of the feet can result from neuropathic changes, and these deformities create extra pressure points which are at high risk of ulceration. Feet should be inspected for common deformities including hammer toes (a fixed flexion deformity of the proximal interphalangeal joint), claw toes (flexion at the distal and proximal interphalangeal joints with dorsiflexion at the metatarsophalangeal joint), prominent metatarsal heads, and pes cavus (high arch).

The basic aims of management are wound closure with prompt healing and prevention of the development of further ulcers.

These management goals can be achieved through a variety of measures including: local wound care (debridement), infection control, ensuring adequate blood supply, VAC therapy, adjunctive therapies, pressure offloading, treating underlying factors (intrinsic and extrinsic), patient education, temperature self-assessment, fat pad augmentation, and specialist shoes.