What are the appropriate referral criteria for a patient with chronic foot pain and suspected neuropathy?

For a patient presenting with chronic foot pain and suspected neuropathy, the appropriate referral criteria depend on the underlying cause and severity.

If the patient has diabetes, suspected neuropathy places them at moderate risk of developing a diabetic foot problem ³,⁵. Patients at moderate or high risk of developing a diabetic foot problem should be referred to the foot protection service ³. High risk factors include previous ulceration or amputation, being on renal replacement therapy, neuropathy and peripheral arterial disease together, or neuropathy in combination with callus and/or deformity ³.

Immediate referral to acute services and the multidisciplinary foot care service is required for limb-threatening or life-threatening diabetic foot problems ³. Examples of these include ulceration with fever or any signs of sepsis, ulceration with limb ischaemia, suspected deep-seated soft tissue or bone infection (with or without ulceration), or gangrene ³. For all other active diabetic foot problems (such as ulceration, infection, chronic limb-threatening ischaemia, gangrene, or suspicion of an acute Charcot arthropathy), referral within one working day to the multidisciplinary foot care service or foot protection service is necessary ³.

Beyond diabetic foot problems, if peripheral limb ischaemia is suspected, an urgent referral is indicated ¹. Chronic limb-threatening ischaemia specifically requires urgent referral to a vascular multidisciplinary team ⁴.

For chronic pain generally, specialist referral is appropriate if non-specialist management is failing, the chronic pain is poorly controlled, or there is significant distress ². Referral is also indicated if there are red flag signs and symptoms that may indicate serious underlying pathology, or if chronic regional pain syndrome is suspected ².