Risk stratification – Summary

Diabetic foot risk stratification and triage

Select the crosses on the image below for more detail

These risk categories relate to the use of the SCI-Diabetes foot risk stratification tool

Risk stratification – High risk

Diabetic foot risk stratification and triage

Risk stratification and triage traffic light - high risk / in remission

These risk categories relate to the use of the SCI-Diabetes foot risk stratification tool

Risk stratification – Low risk

Diabetic foot risk stratification and triage

Diabetic foot risk stratification and triage - low risk

These risk categories relate to the use of the SCI-Diabetes foot risk stratification tool

Risk stratification

The process of foot screening must lead to the individual with diabetes being assigned a risk category, and informed of and understand what that risk category means to them as an individual living with diabetes. According to the assigned risk category this will result in the introduction of a treatment/management plan according to that risk level formulated in consultation with the individual with diabetes, tailored to suit their needs.

The validity of diabetic foot screening is optimized if the process is carried out and recorded in a standardised manner wherever the individual is seen. It is recommended as an area of good practice within the sign guideline that:

‘The result of a foot screening examination should be entered onto an online screening tool, such as the Scottish Care Information – Diabetes Collaboration system (SCI-DC), (now known as SCI – Diabetes), to provide automatic risk stratification and a recommended management plan, including patient information’.

Who should carry out foot screening?

Foot screening may be carried out by any health care professional/worker involved in the care of an individual with diabetes. Examples of these could include the following: podiatrist, podiatry technician, practice nurse, support worker, district nurse, General Practitioner or any other competent healthcare worker.

It is not important who undertakes the screening process as long as the individual carrying this out has the capability and training to do so and is aware of what action to take depending on the results and the individual with diabetes risk status. This capability can be gained by undertaking this training and the test at the end of this module.

How often should an individual undergo diabetes foot screening?

The guideline simply states that:

‘All patients with diabetes should be screened to assess their risk of developing a foot ulcer’.

It also stated that:

‘There is no evidence to support the frequency of screening; however the SIGN guideline group considers that at least annual screening from the diagnosis of diabetes is appropriate’.

Following wide consultation with the Scottish Diabetes Foot Action Group it was decided to update our Traffic Light System (2016) and subsequently the way foot screening is delivered in Scotland to reflect recent evidence (Leese et al 2006), (Crawford et al 2020) and to ‘mirror’ some of the changes that have been introduced to the national Diabetes Retinal Screening (DRS) programme.

Summary of key changes to foot screening

  1. Foot screening for people in the Low Risk category foot move from annual to every 2 years in keeping with clinical evidence.
  2. When an individual transitions from Low Risk to Moderate Risk they should be referred to a podiatrist for assessment (which may be a one off appointment) and be provided with a tailored care package if required, which would be agreed with the individual with diabetes, to reduce the risk of ulceration. Annual foot screening maintained.
  3. All individuals with diabetes deemed to be High/In Remission no longer require a foot screening as foot screening is to determine the risk an individual with diabetes has of developing a foot ulcer and they will never return to a lower risk category. The duty of care and management for all individuals with diabetes deemed to be High/In Remission will fall to podiatry services. The individual with diabetes will work in partnership with podiatry services to create a mutually agreed and documented Treatment/Management plan according to need, which will include education and advice regarding the importance of self-management, with the focus on preventing primary or recurrent ulceration. This Treatment/Management plan may also include ongoing referral to vascular, orthotics, multidisciplinary foot clinics, orthopaedics etc. where appropriate.

03: The purpose of foot screening (NHS Scotland)


Diabetic foot screening is the cornerstone of good diabetic foot care.

The purpose of diabetic foot screening is to carry out a quick, simple, and evidence based screening to determine at what risk an individual is of developing a diabetic foot ulcer, which may lead to an amputation. The individual should be made aware of their foot risk status and have an appropriate treatment/management plan agreed with the individual and implemented if/when required.

Open diary page

The Scottish Intercollegiate Guidelines Network (SIGN 116) is produced in Scotland to guide clinicians on the most up to date, and evidence based practice. This guideline will mainly be of interest to all healthcare professionals/workers involved in the care of individuals with diabetes. The target users are, however, much broader than this, and include individuals living with diabetes, their carers and those who interact with individuals with diabetes outside of the NHS. It will also be of interest to those planning the delivery of services in NHS Scotland and beyond.

The guideline states that:

‘Diabetic foot screening is effective in identifying the level of risk of developing foot ulceration in patients with diabetes’.

It also focuses on keeping the screening process simple and ensuring that all the main risk factors are screened for:

‘Simple tests such as the use of 10g monofilament, palpation of pulses, neuropathy disability score, presence of significant structural abnormality and previous ulceration, when routinely used during screening are effective at predicting ulceration’.

What can be done to help peripheral arterial disease (PAD)?

The screening process for PAD is simple and consists of checking, via palpation, for the two pulses in each foot. If either of these pulses are present during the screening process then the circulation to the foot is perceived to be adequate. These pulses are the Dorsalis Pedis (DP) and the Posterior Tibial (PT). The individual should be asked if they have any signs of intermittent claudication (cramping in the calf muscle after walking a certain distance) and also be given advice regarding lifestyle changes, most importantly stopping smoking.

If during the screening process neither of the pulses can be palpated or the individual presents with any of the aforementioned problems they may need to be referred for a more in depth assessment of their PAD, leading in some cases to the implementation of an Education / Management plan to try and improve the situation or referral to vascular services for surgical intervention where appropriate.