Recommendation 1: In patients with a diabetic foot infection (DFI) with an open wound, we suggest doing a probe to bone (PTB) test to aid in diagnosis (Grade 2C).

Recommendation 2: In all patients presenting with a new DFI, we suggest that serial plain radiographs of the affected foot be obtained to identify bone abnormalities (deformity, destruction) as well as soft tissue gas and radiopaque foreign bodies (Grade 2C).

Recommendation 3: For those patients who require additional (i.e., more sensitive or specific) imaging, particularly when soft tissue abscess is suspected or the diagnosis of osteomyelitis remains uncertain, we recommend using magnetic resonance imaging (MRI) as the study of choice. MRI is a valuable tool for diagnosis of osteomyelitis if the PTB test is inconclusive of if the plain film is not useful (Grade 1B).

Recommendation 4: In patients with suspected DFO for whom MRI is contraindicated or unavailable, we suggest a leukocyte or antigranulocyte scan, preferably combined with a bone scan as the best alternative (Grade 2B).

Recommendation 5: In patients at high risk for DFO, we recommend that the diagnosis is most definitively established by the combined findings on bone culture and histology (Grade 1C). When bone is débrided to treat osteomyelitis, we recommend sending a sample for culture and histology (Grade 1C).

Recommendation 6: For patients not undergoing bone débridement, we suggest that clinicians consider obtaining a diagnostic bone biopsy when faced with diagnostic uncertainty, inadequate culture information, or failure of response to empirical treatment (Grade 2C).