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Medicine Science
REVIEW ARTICLE International
Medical Journal
Medicine Science 2022;11(1):429-32
Role of screening in preventing diabetic foot storm
Amit Kumar C Jain
Amit Jain's Diabetic Foot and Wound Research Unit, Amit Jain's Institute of Diabetic Foot and Wound Care, Brindhavvan Areion Hospital, Bengaluru,
Karnataka, India
Received 19 May 2021; Accepted 10 August 2021
Available online 23.12.2021 with doi: 10.5455/medscience.2021.05.180
Copyright@Author(s) - Available online at www.medicinescience.org
Content of this journal is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Abstract
With diabetes mellitus increasing at an alarming rate worldwide, so are its complications. A dreaded and neglected complication of diabetes is diabetic foot. Patients with
diabetic foot are at risk of amputation which can lead to increase in morbidity and mortality adding further problems. This article aims to shed light on the new Amit
Jain’s classification of problems in diabetic foot and our understanding of the new term “Diabetic foot storm”. It summarizes on the commonly available screening tool
worldwide with focus on the Amit Jain’s screening tool and need to use them as one of the strategies that can prevent a diabetic foot storm in patient’s life.
Keywords: Diabetes, foot, storm, Amit Jain’s, screening
Introduction It was seen in one of the authors earlier series that as high as
80% of patients in teaching hospital underwent some form of
It is estimated that by year 2020, there will be more than 700 million amputation [10]. Diabetic foot ulcers are known to precede in 85%
people living with diabetes [1]. This chronic non-communicable of amputation in foot [11].
disease is a major global health problem affecting large segment of
the population [2, 3]. In developing countries, it is seen that 75% When there are so many bad news associated with diabetic foot,
of patients with diabetes are above 45 years age [2]. In India itself, there is some good news too. One such good news is that more
there are around 40.9 million people with diabetes [4]. than 75% of amputation can be prevented through education and
screening [12].
One such complication of diabetes is the diabetic foot that has
significant impact on patient’s quality of life [5, 6]. Such is the The diabetic foot storm
status of diabetic foot that, 15% of people with diabetes will be
affected with ulcers during their life [7]. Around 2-6% of the A new classification for problems in diabetic foot was proposed
patients will develop diabetic foot ulcers annually [8]. More than that divided them into 6 simple categories [13]. Category 1 is
50% of these ulcers will get infected and many may end up in the preponderant problem which is diabetes mellitus itself that
some form of amputation [9]. causes the foot problems [Table 1]. Category 2 is the current
problem which the patient may be suffering and they include
ulcers, gangrene, cellulitis, abscess, etc [13, 14]. Category 3 is the
concurrent problems. It is well known that diabetes have many
other associated complications apart from diabetic foot [15].
Often, they can occur together in same patient. Some of the known
concurrent problems that can occur in diabetic foot patient are
hypertension, stroke, chronic kidney disease, etc [13]. Category
4 is the recurrent problems in diabetic foot patients. They include
re-ulcerations, readmission, recurrent cellulitis, reamputation, etc
*Corresponding Author: Amit Kumar C Jain, Amit Jain's Institute of Diabetic [13, 16]. For example, a study by Skoutas et al showed that 21.5%
Foot and Wound Care, Brindhavvan Areion Hospital, Chamarajpet 4th main, of patients had reamputations within 18 months of follow-up [16].
Bengaluru-560004, Karnataka, India, Email- [email protected]
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doi: 10.5455/medscience.2021.05.180 Med Science 2022;11(1):429-32
It is obvious that it is a vicious cycle that is often interconnected problem too. Examples include prosthesis related issues, mortality
when patients end in recurrent problems. For example, reulceration following amputations, bed sores, DVT, etc [13, 14]. Category 6 is
could lead to recurrent admission and reamputations. Category supplement problems that can be due to diabetic foot like job loss,
5 is subsequent problems. Often, it is seen that patients when cost of treatment leading to financial losses, etc [13, 17].
getting treated for diabetic foot problems will have subsequent
Table 1. The new Amit Jain’s classification of problems in diabetic foot
Categories of foot problems Type Examples
Category 1 Preponderant Diabetes mellitus
Category 2 Current Ulcer, Gangrene, Abscess, etc
Category 3 Concurrent Hypertension, CKD, IHD, etc
Category 4 Recurrent Re-amputation, Re-ulceration, Re-admissions, etc
Category 5 Subsequent Mortality, Major amputations, etc
Category 6 Supplement Depression, Loss of job, Financial issues, etc
Based on this Amit Jain’s classification of problems in diabetic professionals [18]. Studies have shown that foot was evaluated in
foot, the author had coined a new term “Diabetic foot storm” that diabetics only in 12-20% of the times [9, 19].
would play an important role in creating global awareness of this
disease [14, 17]. Screening of the foot plays a vital role in reducing the diabetes
related foot problems like ulcers, amputations, morbidities, ulcer
If a patient has gone through any of the 5 or more problems, then recurrences, etc [20]. It is recommended that every person who has
he is considered to have gone through diabetic foot storm in his diabetes has to be screened at-least annually [21].
life [17]. Patients who have gone through 3 problems should be
warned of a storm (Figure 1) and those who have gone through 4 The 3 screening tool that are known in diabetic foot are the In-
problems, have an impending storm in their life [14, 17]. low’s screening tool, simplified 60 second screening tool and Amit
Jain’s screening tool [22, 23].
Each screening tool has their own merits and demerits and the
clinician can choose which ever suits in his region and in his
population but the aim is to ensure that the screening is done
for the diabetic foot and it should not be neglected. Developing
original screening tools especially that eases a clinician’s life is
difficult, though it is easy to condemn any screening tool.
The In-low’s 60 second screening tool comprises of around 12
items that are scored from 0 to 25 [24, 25]. This screening tool
helps clinicians to identify the risks of diabetic foot [24]. However,
it was noted that this screening tool required longer time to perform
than it stated and it ranged from 2 to 21 minutes [26]. Subsequently,
a simplified 60 second diabetic foot screening tool was developed
[26]. This screening tool was stated to be user-friendly and was
developed for low and middle income countries and can be used
in high income countries also [26]. Both these screening tool
Figure 1. The diabetic foot storm based on Amit Jain’s classification of problems however requires chart as they are difficult to be remembered
in diabetic foot even by specialist foot surgeon leave apart the general doctors or
paramedical health workers.
Diabetic foot screening
Another screening tool that was recently proposed was the Amit
There are distinct prevention strategies that can be employed Jain’s screening tool (Figure 2) which is also known as Amit
to prevent or delay the diabetic foot storm. Of all such known Jain’s triple assessment, Amit Jain’s LFT screening tool, etc [18,
strategies, diabetic foot screening should be considered to be a 22, 23]. This screening tool is extremely simple, easy to perform,
cornerstone among healthcare providers. practical, economical, can be remembered and done by any health
care professional in any part of the world [22, 23]. This screening
In spite of knowing the benefits of screening in prevention
tool addresses the triopathy efficiently through its 3 components
of diabetic foot problems, it is often omitted by health care
namely the Look component, the Feel component and the Test
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doi: 10.5455/medscience.2021.05.180 Med Science 2022;11(1):429-32
component [22]. This screening tool also has a simple scoring assessment for foot was derived from concept of triple assessment
system that was recently validated and it divided the patient of breast followed universally for a breast lump and this screening
into low risk and high risk category [16]. The Amit Jain’s triple tool was also aimed to be followed in similar lines [27].
Figure 2. Amit Jain’s Linear Foot Test which is also known as Amit Jain’s triple assessment
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