Maintaining healthy skin on the lower limb is crucial in preventing a range of complications, particularly for individuals with conditions that increase the risk of skin injuries, such as diabetes or skin conditions. Podiatrists, as specialists in the foot and ankle, play a vital role in early identification and prevention of lower limb skin injuries.

Historically, there has been some debate – or a lack of clear understanding – over where ‘responsibility’ lies for issues relating to the lower limb. Definitions of where the lower limb ends and the foot begins may vary and cause confusion over the role of different clinicians in prevention and management.

As such, a multidisciplinary group of experts met online on 30th May 2024 to discuss the role of the podiatrist and how their expertise can benefit patients who are at risk of all types of lower limb skin damage (not only the foot). This document reflects the discussion of the experts and how the findings can be applied to practice.

This document aims to:

Clarify definitions of the lower limb, the foot and related terminology
Identify risk factors common for both lower limb and foot-related changes
Encourage effective communication and a multidisciplinary team (MDT) approach to promote early identification and continuity of care for patients
Explore ways in which prevention and early identification of lower limb changes can be optimised as part of the existing practice of podiatrists
Increase awareness and confidence for all clinicians involved with the foot and lower limb to deal with issues promptly as they arise and know who to speak to for further advice or if a referral is needed.

Podiatrists have a wide range of skills such as assessing skin and musculoskeletal (MSK) conditions, identifying risk factors, and implementing targeted interventions, which are instrumental in mitigating the risk of developing an issue with the foot and associated complications. Through regular comprehensive foot examinations, podiatrists can detect early signs of skin damage, such as calluses, blisters, or areas of increased pressure, and promptly address these issues before they progress to more serious ulcerations.

This in turn means podiatrists may also be ideally placed to be more involved in the prevention and early identification of skin damage affecting the lower leg (as opposed to the foot), such as venous hypertension, skin tears, oedema and venous leg ulcers (VLUs), to reduce patients’ cumulative risk of such injuries and their associated complications if left untreated.

The growing prevalence of chronic wounds, such as DFUs and VLUs, and the significant strain placed on healthcare services, necessitate the need for the early identification and prevention of lower leg injuries, with a clear MDT approach wherever possible so that early signs are not missed.

Karen Ousey, Chair

Download the full consensus document below

REFERENCES:

Anderson I, Smith G (2014) Compression Made Easy. Wounds UK

Ashby RL, Gabe R, Ali S, Adderley U (2014) Clinical and cost-effectiveness of compression hosiery versus compression bandages in treatment of venous leg ulcers (Venous leg Ulcer Study IV, VenUS IV): A randomised controlled trial. Lancet 383(9920): 871-9

Bassett K, Orsted HL, Rosenthal S (2019) Creating a unified approach to best practice in wound care. Wounds International 10(2): 16-9

Beeckman D, Campbell K, Le Blanc K (2020) Best practice recommendations for holistic strategies to promote and maintain skin integrity. Wounds International

Bermark S, Wahlers B, Gerber A et al (2018) Prevalence of skin tears in the extremities in inpatients at a hospital in Denmark. Int Wound J 15(2): 212-7

Bianchi J, Vowden K, Whitaker J (2012) Chronic oedema Made Easy. Wounds UK

British Lymphology Society (2022) Guidelines on the management of cellulitis in lymphoedema. Available at: https://www.thebls.com/documents-library/ guidelines-on-the-management-of-cellulitis-in-lymphoedema (accessed 02.07.2024)

Callaghan R, Cowdell F, Danby S et al (2018) Best practice statement: Maintaining skin integrity. Wounds UK

Carville K, Leslie G, Osseiran-Moisson R et al (2014) The effectiveness of a twice-daily skin-moisturising regimen for reducing the incidence of skin tears. Int Wound J 11(4): 446-53

Cowley E, Bullen B, Casey J (2023) Modernisation and Reform of the 21st Century Podiatrist. Available at: https://rcpod.org.uk/workforceprogramme/modernisation-and-reform (accessed 27.06.2024)

Elwell R (2014) Ten top tips for toe bandaging for chronic oedema/lymphoedema. Wound Essentials 9(2): 44-6

Fletcher J (2023) Can you help us to make every contact count and eliminate avoidable pressure ulcers in all health and care settings? Wounds UK 19(4): 94-5

Fletcher J, Atkin L, Dowsett C et al (2016) Best Practice Statement: Holistic management of venous leg ulceration. Wounds UK

Fletcher J, Atkin L, Dowsett C et al (2019) Best practice statement: Addressing complexities in the management of venous leg ulcers. Wounds UK

Fletcher J, Atkin L, Bolton L et al (2021) Compression hosiery: a patient-centric approach (3rd edition). Wounds UK

Fletcher J, Atkin L, Dhoonmoon L (2022b) Best practice statement: Holistic management of venous leg ulceration (2nd edition). Wounds UK

Fletcher J, Darke J, Dhoonmoon L et al (2022a) Best practice statement: Active treatment of non-healing wounds in the community. Wounds UK

Fletcher J, Dowsett C, Holloway S et al (2020) Best practice statemen: Management of lower limb skin tears in adults. Wounds UK

Guest JF, Fuller GW, Vowden P (2020) Cohort study evaluating the burden of wounds to the UK’s National Health Service in 2017/2018: Update from 2012/2013. BMJ Open 10(12): e045253

Harding K, Dowsett C, Fias L et al (2015) Simplifying venous leg ulcer management: consensus recommendations. Wounds International

Hurlow J, Bowler PJ (2022) Acute and chronic wound infections: microbiological, immunological, clinical and therapeutic distinctions. J Wound Care 31(5): 436-45

Inamadar AC, Palit A (2013) Critical care in dermatology. Jaypee Medical Publishing, Delhi

Jefferies BJ, Patel L, Khanna A (2023) Referral and management of pretibial lacerations in two district general hospitals. Cureus 15(1): e34231

Leaper D (2015) An overview of surgical site infection. Wounds UK 11(5): 14-9

Leaper DJ, Harding KG (1998) Wounds: Biology and management. Oxford University Press

LeBlanc K, Baranoski S (2018) Skin tears: The under-appreciated enemy of aging skin. Wounds International 9(1): 6-10

LeBlanc K, Campbell K, Beeckman D et al (2018) Best practice recommendations for the prevention and management of skin tears in aged skin. Wounds International

Levine J (2020) Clinical aspects of aging skin: Considerations for the wound care practitioner. Adv Skin Wound Care 33(1): 12-9

Moncrieff G, Van Onselen J, Young T (2015) The role of emollients in maintaining skin integrity. Wounds UK 11(1): 68-74

Moore Z, O’Brien G, Atkin L et al (2022) Patients presenting with ‘red legs’: Differential diagnosis and the role of compression. Wounds International

Morgan-Jones R, Bishay M, Hernández-Hermoso JA et al (2019) Incision care and dressing selection in surgical wounds: Findings from a meeting of international surgeons. Wounds International

Najjar PA, Smink DS (2015) Prophylactic antibiotics and prevention of surgical site infections. Surg Clin N Am 95(2): 269-83

National Health Service (2010) Skincare of patients receiving radiotherapy. NHS Quality Improvement Scotland

National Health Service (2017) Diabetes Footcare Pathway Blueprint. Available at: https://www.england.nhs.uk/north/wp-content/uploads/sites/5/2018/05/NWCSN_Diabetes_Footcare_Final_Report_2017-1.pdf (accessed 27.06.2024)

National Health Service (2022) Human papillomavirus. Available at: https://www.nhs.uk/conditions/human-papilloma-virus-hpv/ (accessed 01.07.2024)

National Health Service England (2015) Role of pharmacists is set to grow and grow. Available at: https://www.england.nhs.uk/blog/keith-ridge-2/ (accessed 02.07.2024)

National Health Service England (2017) NHS RightCare scenario: The variation between suboptimal and optimal pathways. Available at: https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2017/02/nhs-rightcare-bettys-story-app1.pdf (accessed 28.06.2024)

National Health Service England (2024) Podiatrist. Available at: https://www.hee.nhs.uk/our-work/allied-health-professions/podiatrist (accessed 27.06.2024)

National Wound Care Strategy Programme (2020) Lower limb – Recommendations for Clinical Care. Available at: https://www.ahsnnetwork.com/wp-content/uploads/2020/11/Lower-Limb-Recommendations-20Nov20.pdf (accessed 28.06.2024)

National Wound Care Strategy Programme (2024) Leg ulcer recommendations. Available at: https://www.nationalwoundcarestrategy.net/wp-content/uploads/2024/07/NWCSP-Leg-Ulcer-Recommendations-final-version-15.07.2024.pdf (accessed 29.07.2024)

National Institute for Health and Clinical Excellence (2012) Peripheral arterial disease: diagnosis and management. Available at: https://www.nice.org.uk/guidance/cg147 (accessed 02.07.2024)

National Institute for Health and Clinical Excellence (2013) Varicose veins: diagnosis and management. Available at: https://www.nice.org.uk/guidance/cg168 (accessed 02.07.2024)

National Institute for Health and Clinical Excellence (2015) Tacrolimus and pimecrolimus for atopic eczema (TA82): Quick reference guide. Available at: https://www.nice.org.uk/guidance/ta82 (accessed 02.07.2024)

National Institute for Health and Care Excellence (2019) Diabetic foot problems: Prevention and management. Available at: https://www.nice.org.uk/guidance/ng19/chapter/Recommendations#care-across-all-settings (accessed 27.06.2024)

National Institute for Health and Care Excellence (2022) Venous eczema and lipodermatosclerosis. Available at: https://cks.nice.org.uk/topics/venous-eczema-lipodermatosclerosis/ (accessed 01.07.2024)

North American Nursing Diagnosis Association (2018) Nursing diagnoses: Definitions and classification. Available at: https://nanda.org/publications-resources/publications/nanda-international-nursing-diagnoses/ (accessed 02.07.2024)

Olsson M, Järbrink K, Divakar U et al (2019) The humanistic and economic burden of chronic wounds: A systematic review. Wound Repair Regen 27(1): 114-25

Ousey K, Atkin L, Conway B et al (2021) Compression therapy for pharmacy teams. Wounds UK

Rafter L, Reynolds T, Rafter M (2016) An audit of patient outcomes in the management of skin tears using silicone dressings. Wounds UK 12(2): 70-8

Rappl LM (2008) Physiological changes in tissues denervated by spinal cord injury tissues and possible effects on wound healing. Int Wound J 5(3): 435-44

Rayner R, Carville K, Leslie G, Roberts P (2015) A review of patient and skin characteristics associated with skin tears. J Wound Care 24(9): 406-14

Royal College of Podiatry (2024) What is a podiatrist? Available at: https://rcpod.org.uk/become-a-podiatrist/what-is-a-podiatrist (accessed 27.06.2024)

Shipman AR, Millington GWM (2011) Obesity and the skin. Br J Dermatol 165(4): 743-50

Sochen JE (1994) Orthopedic wounds. Am J Surg 167(1A): S52-4

Vernon T, Moore K, Vowden K, Vowden P (2019) A safe first-line approach to managing skin tears within an acute care setting (part 1). Wounds UK 15(2): 2-7

Voegeli D (2007) Factors that exacerbate skin breakdown and ulceration. In: Skin Breakdown, the silent epidemic. Smith and Nephew Foundation. Hull

World Union of Wound Healing Societies (2020) Optimising wound care through patient engagement. Wounds International

Wounds UK (2018) Best practice statement: Maintaining skin integrity. Wounds UK

Wounds UK (2020) Best Practice Statement: Management of lower limb skin tears in adults. Wounds UK

This document has been developed by The Diabetic Foot Journal and supported by Biocomposites, Essity and L&R.

Amputation inequalities across a large metropolitan area of England and effect of a ‘high-risk’ rather than ‘diabetes-only’ multidisciplinary approach to lower-limb wound care 2015/16 to 2021/22

The Diabetic
Foot Journal

Prevention and early identification of lower limb skin injuries: The role of the podiatrist

Demystifying infection in the diabetic foot

Prevention and early identification of lower limb skin injuries: The role of the podiatrist

Consensus document: Improving offloading for the foot in diabetes – Use of total contact casting in practice

A good sense of EWMA

Scottish Diabetes Foot Action Group: The WIfI Project 2024

Amputation inequalities across a large metropolitan area of England and effect of a ‘high-risk’ rather than ‘diabetes-only’ multidisciplinary approach to lower-limb wound care 2015/16 to 2021/22

The Diabetic Foot Journal

Prevention and early identification of lower limb skin injuries: The role of the podiatrist

Demystifying infection in the diabetic foot

Prevention and early identification of lower limb skin injuries: The role of the podiatrist

Consensus document: Improving offloading for the foot in diabetes – Use of total contact casting in practice

A good sense of EWMA

Scottish Diabetes Foot Action Group: The WIfI Project 2024

Understanding personality traits: could this help us support better foot self-care behaviours in people with diabetes?

Amputation inequalities across a large metropolitan area of England and effect of a ‘high-risk’ rather than ‘diabetes-only’ multidisciplinary approach to lower-limb wound care 2015/16 to 2021/22

The Diabetic
Foot Journal