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Commemorating Ten Years Of “Toe And Flow”

The Journal of the American Podiatric Medical Association (JAPMA) recently published online a collection of Special Communications to commemorate the decade since establishment of the “Toe and Flow” model for multidisciplinary care of the diabetic foot.1-4  

While so much has changed over the past ten years, the risk for ulceration, infection and amputation in people with diabetes continues to rise, representing a significant challenge to patients, providers and institutions across the global healthcare spectrum.5,6 Of course, “Toe and Flow” did not appear out of nowhere. Rather, it was the product of years of collaboration between the American Podiatric Medical Association (APMA) and Society for Vascular Surgery (SVS). More importantly, it emerged from the common belief that caring for the diabetic foot should not be a “Sisyphean task” (i.e. laborious and futile), but “rather than toiling heroically in isolation only to perish like the solitary Achilles, perhaps we can be more ‘Homeric’ and team up.”7  

Indeed, over the past ten years this “team approach” formed the basis for the development of many more interdisciplinary limb preservation units, in this country and abroad, including the addition of other key specialties such as infectious disease, orthopedics, plastic surgery and physical therapy.1,2 And, when it comes to forming these teams, there should not be a “one size fits all” approach. For example, in developing the limb preservation clinic during my time at Kaiser Permanente, we leveraged the efficiency of the integrated healthcare system along with advanced telemedicine capabilities to form a cross-regional multispecialty clinic. 

The “Toe and Flow” model also led to the development of high-quality and evidence-based classification systems and practice guidelines. In particular, the Wound, Ischemia and Foot Infection (WIfI) classification system provides a reliable means for stratifying the degree of limb threat, predicting amputation risk at one year and directs the need for revascularization.1 Furthermore, the Global Vascular Guidelines (GVG) provides evidence-based, best-practice recommendations for the diagnosis and treatment of chronic limb-threatening ischemia (CLTI).4

The ten-year anniversary of this groundbreaking collaboration between podiatric and vascular specialists is certainly worthy of celebration. Yet, there is so much more work left to do! As a former SALSA fellow, I had the privilege of experiencing “Toe and Flow” first hand, and gained enormous respect and immeasurable appreciation for those who came before me.  It is truly incredible to look back at the past ten years and marvel at how we got here. But, let’s continue to work together with our vascular colleagues and imagine where we will be in another ten years. 

Dr. Isaac is the Director of Research with Foot & Ankle Specialists of the Mid-Atlantic (FASMA). He is a Diplomate of the American Board of Foot and Ankle Surgery.


1. Armstrong DG, Conte MS, Rogers LC, Mills JL. The offspring of Sisyphus: steady progress in the decade since the "Toe and Flow." JAPMA-JVS Special Issue on Limb Preservation. J Am Podiatr Med Assoc. 2021. Available at doi: . Accessed March 26, 2021.

2. Serino F, Montero-Baker M, Fernando ME, Armstrong DG. Toward an interdisciplinary approach to diabetic limbs in the era of functional limb preservation: "can we preserve this limb?" meets "should we preserve this limb?" J Am Podiatr Med Assoc. 2021. Available at doi: . Accessed March 26, 2021.

3. Karabanow AB, Zaimi A, Suarez LB, Iafrati MD, Allison GM. An analysis of guideline consensus for the prevention, diagnosis and management of diabetic foot ulcers. J Am Podiatr Med Assoc. 2021. Available at doi: . Accessed March 26, 2021.

4. Rogers LC, Conte MS, Armstrong DG, Lavery LA, Mills JL, Neville RF. The significance of the global vascular guidelines for podiatrists: answers to key questions in the diagnosis and management of the threatened limb. J Am Podiatr Med Assoc. 2021.  Available at doi: . Accessed March 26, 2021.

5.  Armstrong DG, Swerdlow MA, Armstrong AA, Conte MS, Padula WV, Bus SA. Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. J Foot Ankle Res. 2020;13(1):1-4.

6. Zhang Y, Lazzarini PA, McPhail SM, van Netten JJ, Armstrong DG, Pacella RE. Global disability burdens of diabetes-related lower-extremity complications in 1990 and 2016. Diabetes Care. 2020;43(5):964-974.

7. Mills JL, Armstrong DG, Andros G. Rescuing Sisyphus: the team approach to amputation prevention. J Am Podiatr Med Assoc. 2010;100(5):315–316. 

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