Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this guideline the IWGDF, the European Society for Vascular Surgery and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development, and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post‐surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.

Background: The ankle brachial index (ABI) is widely used in clinical practice as a non‐invasive method to detect the presence and severity of peripheral arterial disease (PAD). Current guidelines suggest that it should be used to monitor potential progression of PAD in affected individuals. As such, it is important that the test is reliable when used for repeated measurements, by the same or different health practitioners. This systematic review aims to examine the literature to evaluate the inter‐ and intra‐rater reliability of the ABI.Methods: A systematic search of MEDLINE, EMBASE and CINAHL Complete was conducted to 20 January 2019. Two authors independently reviewed and selected relevant studies and extracted the data. Methodological quality was determined using the Quality Appraisal of Reliability (QAREL) Checklist.Results: Fifteen studies of ABI reliability in a range of patient populations were identified as suitable for inclusion in the review: seven considered inter‐rater reliability, four intra‐rater reliability, and four studies evaluated both inter‐ and intra‐rater reliability. Inter‐rater reliability was found to be highly variable, with intraclass correlation coefficients (ICC's) ranging from poor to excellent (ICC 0.42–1.00), while intra‐rater also demonstrated considerable variation, with ICCs from 0.42–0.98. Meta‐analysis was not possible due to the lack of statistical information reported.Conclusions: Results of included studies suggest the inter‐ and intra‐tester reliability of the ABI is acceptable. However, inconsistencies in obtaining systolic pressure measurements, calculating ABI values, and incomplete reporting of methodologies and statistical analysis make it difficult to determine the validity of the results of included studies. Further research, with more consistent reliability methodology, statistical analysis and reporting conducted in populations at risk of PAD is needed to conclusively determine the ABI reliability.

Low back pain (LBP) is a significant public health problem in Western industrialised countries and has been reported to affect up to 80% of adults at some stage in their lives. It is associated with high health care utilisation costs, disability, work loss and restriction of social activities. An intervention of foot orthoses or insoles has been suggested to reduce the risk of developing LBP and be an effective treatment strategy for people suffering from LBP. However, despite the common usage of orthoses and insoles, there is a lack of clear guidelines for their use in relation to LBP. The aim of this review is to investigate the effectiveness of foot orthoses and insoles in the prevention and treatment of non specific LBP.

Background: The Foot Posture Index (FPI) provides an easily applicable, validated method for quantifying static foot posture. However there is limited evidence relating to the ability of the FPI to predict dynamic foot function. This study aimed to assess the relationship between dynamic rearfoot motion and FPI scores in pronated and normal foot types.Methods: 40 participants were recruited with equal numbers of pronated and normal foot types as classified by their FPI score. Three dimensional rearfoot motion was collected for each of the participants. Dynamic maximum rearfoot eversion was correlated with the total FPI score across all participants and within the normal and pronated foot types. Linear correlations were performed between components of the total FPI scores measuring frontal plane rearfoot position and maximum rearfoot eversion. The capacity of the total FPI score to predict maximum frontal plane motion of the rearfoot was investigated using linear regression analysis.Results: The correlation between the total FPI score and maximum rearfoot eversion was strongly positive (r = 0.92, p < 0.05). Correlation performed on data subsets demonstrated the pronated foot type (FPI = +6 to +9) and maximum rearfoot eversion angle were more strongly positively correlated (r = 0.81, p < 0.05) than the normal foot type (FPI = 0 to +5) and maximum rearfoot eversion (r = 0.76, p < 0.05). Correlations between frontal plane rearfoot FPI score and frontal plane motion during gait were strongly positive, (r = 0.79 p < 0.05 pronated group, r = 0.71 p < 0.05 normal group), however were less strong than the total FPI score and rearfoot motion. Linear regression analysis demonstrated a significant and strong relationship between the total FPI score and maximum rearfoot eversion (r² = 0.85, p < 0.001).Conclusions: The results of this study suggest the FPI has strong predictive ability for dynamic rearfoot function. This will assist in clinical screening and research by allowing easy classification by functional foot type. Positive correlations between frontal plane rearfoot measurements and maximum rearfoot eversion suggest the FPI may identify dominant planar components of dynamic rearfoot motion and warrants further investigation.

Introduction: The presence of peripheral artery disease (PAD) confers a significantly increased risk of failure to heal and major lower limb amputation for people with diabetes‐related foot ulcer (DFU). Determining performance of non‐invasive bedside tests for predicting likely DFU outcomes is therefore key to effective risk stratification of patients with DFU and PAD to guide management decisions. The aim of this systematic review was to determine the performance of non‐invasive bedside tests for PAD to predict DFU healing, healing post‐minor amputation, or need for minor or major amputation in people with diabetes and DFU or gangrene.Methods: A database search of Medline and Embase was conducted from 1980 to 30 November 2022. Prospective studies that evaluated non‐invasive bedside tests in patients with diabetes, with and without PAD and foot ulceration or gangrene to predict the outcomes of DFU healing, minor amputation, and major amputation with or without revascularisation, were eligible. Included studies were required to have a minimum 6‐month follow‐up period and report adequate data to calculate the positive likelihood ratio (PLR) and negative likelihood ratio for the outcomes of DFU healing, and minor and major amputation. Methodological quality was assessed using the Quality in Prognosis Studies tool.Results: From 14,820 abstracts screened 28 prognostic studies met the inclusion criteria. The prognostic tests evaluated by the studies included: ankle‐brachial index (ABI) in 9 studies; ankle pressures in 10 studies, toe‐brachial index in 4 studies, toe pressure in 9 studies, transcutaneous oxygen pressure (TcPO₂) in 7 studies, skin perfusion pressure in 5 studies, continuous wave Doppler (pedal waveforms) in 2 studies, pedal pulses in 3 studies, and ankle peak systolic velocity in 1 study. Study quality was variable. Common reasons for studies having a moderate or high risk of bias were poorly described study participation, attrition rates, and inadequate adjustment for confounders. In people with DFU, toe pressure ≥30 mmHg, TcPO₂ ≥25 mmHg, and skin perfusion pressure of ≥40 mmHg were associated with a moderate to large increase in pretest probability of healing in people with DFU. Toe pressure ≥30 mmHg was associated with a moderate increase in healing post‐minor amputation. An ABI using a threshold of ≥0.9 did not increase the pretest probability of DFU healing, whereas an ABI <0.5 was associated with a moderate increase in pretest probability of non‐healing. Few studies investigated amputation outcomes. An ABI <0.4 demonstrated the largest increase in pretest probability of a major amputation (PLR ≥10).Conclusions: Prognostic capacity of bedside testing for DFU healing and amputation is variable. A toe pressure ≥30 mmHg, TcPO₂ ≥25 mmHg, and skin perfusion pressure of ≥40 mmHg are associated with a moderate to large increase in pretest probability of healing in people with DFU. There are little data available evaluating the prognostic capacity of bedside testing for healing after minor amputation or for major amputation in people with DFU. Current evidence suggests that an ABI <0.4 may be associated with a large increase in risk of major amputation. The findings of this systematic review need to be interpreted in the context of limitations of available evidence, including varying rates of revascularisation, lack of post‐revascularisation bedside testing, and heterogenous subpopulations.