CLINICAL FOCUS
Diabetic foot ulcer management:
the podiatrist’s perspective
Martin Turns
Martin Turns is Lead Podiatrist in Diabetes (Brighton and Hove), Sussex Community Trust

 Email: martin.turns@nhs.net
C linical studies suggest that foot ulcers precede 84%
of non-traumatic lower extremity amputations in
individuals with diabetes (Pecoraro at al, 1990).
Ulceration and amputation substantially reduce quality of
life and are associated with high mortality. 50% of patients
with diabetes who have had an amputation survive a
further 2 years. Even without amputation, the prognosis is
poor. Only around 56% of patients with diabetes who have
had foot ulcers survive for 5 years (NHS Diabetes, 2012).
The cost of ulceration and
amputation in diabetes
In 2010/11, 8.8% of all hospital admissions (with at
least one overnight stay) for patients with diabetes
involved a foot problem. There were 5917 non-traumatic
lower extremity amputation admissions, and more than
66 000 other admissions involving foot complications.
Furthermore, the average length of hospital stay for people
with diabetic foot problems is 13  days longer than for
people with diabetes who do not have foot problems
(NHS Diabetes, 2012).
Diabetic foot complications
Diabetic foot complications result from the following two
broad pathologies (Table 1).
w Neuropathic feet, where good circulation is present,
are warm, numb, dry and usually painless. Neuropathic
ABSTRACT
Diabetic foot complications result from two broad pathologies—neuropathic
and neuro-ischaemic feet. It is important for diabetic patients to have at
least a yearly review of foot ulcer risk factors, and they should have a
corresponding risk classification agreed based on this assessment. Diabetic
foot ulcer assessment should include a wound classification tool, which can
give an indication of wounds at greater risk of non-healing or amputation.
The treatment of diabetic foot ulcers should be part of a comprehensive care
plan that should also include treatment of infection, frequent debridement (if
deemed appropriate by a skilled specialist clinician), biomechanical offloading,
blood glucose control and treatment of comorbidities. Clinicians should base
dressing selection on the wound’s location, size and depth, amount of exudate,
presence of infection or necrosis and the condition of the surrounding tissue.
KEY WORDS
w Tissue viability w Wound assessment w Wound management w Primary care
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ulcers and Charcot joints are two main complications.
w Neuro-ischaemic feet are cool and pulses are absent.
Pain can occur at rest and ulceration at the edges of
the foot from localised pressure damage can lead to
gangrene or tissue necrosis (National Institute for
Health and Care Excellence (NICE), 2004).
Infection
Foot infections (Figure  1) are a common and serious
problem in people with diabetes. While all wounds
are colonised with microorganisms, the presence of
infection is defined by two or more ‘classic’ findings:
inflammation and/or purulence. Most diabetic foot
infections are polymicrobial, with aerobic Gram-positive
cocci and especially staphylococci, the most common
causative organisms. Infections are then classified into
mild (superficial and limited in size and depth), moderate
(deeper or more extensive) or severe (accompanied by
systemic signs or metabolic sepsis) (Lipsky et al, 2012).
Risk of foot ulceration
The risk of ulcers or amputations is increased in people
who have the following health factors (American Diabetes
Association, 2013):
w Previous amputation
w Past foot ulcer history
w Peripheral neuropathy
w Foot deformity
w Peripheral arterial disease
w Visual impairment
w Diabetic nephropathy (especially kidney dialysis patients)
w Poor glycemic control
w Cigarette smoking
Every patient with diabetes should receive at least a yearly
annual foot assessment to check for the presence of these risk
factors and then be given a risk classification. The foot review
should be performed during the general diabetic annual
review, performed in either primary or secondary care.
Diabetes UK (2011) produced Putting Feet First, a document
which suggested everyone with diabetes should receive an
© 2013 MA Healthcare Ltd
annual review where their risk score is assessed and linked to a
management plan corresponding to the risk score (see Table 2).
Classification of active ulceration
Assessment of the patient with active foot ulceration is an
integral part of the management process, and foot ulcer
Wound Care, December 2013
 CLINICAL FOCUS

a b classification tools can help deliver effective care. Various

wound classification systems are used in diabetic foot care,
and they attempt to encompass the characteristics of an ulcer.
It seems that poor clinical outcomes are generally
associated with infection, peripheral arterial disease and
increasing wound depth. An easy-to-use classification system
that provides a uniform description of an ulcer will help to
plan treatment strategies and predict outcomes in terms of
healing and lower-limb amputations (Oyibo et al, 2001).
Martin Turns

Wagner classification
The Wagner system assesses ulcer depth and the presence
Figure 1. (a) Diabetic toe with infection. (b) Diabetic of osteomyelitis or gangrene by using the following grades:
toe following management with oral antibiotics and grade 0 (pre- or post-ulcerative lesion), grade 1 (partial/full
topical antimicrobial dressing. thickness ulcer), grade  2 (probing to tendon or capsule),
grade 3 (deep with osteitis), grade 4 (partial foot gangrene),
Table 1. Symptoms and signs of neuropathic versus and grade 5 (whole foot gangrene) (Wagner, 1981).
ischemic ulcers
Neuropathic ulcer Ischemic ulcer The University of Texas (UT) system
The UT system assesses ulcer depth, the presence of
Painless Painful wound infection and the presence of clinical signs of
lower-extremity ischemia. The grades of the UT system
Normal pulses Absent pulses are as follows: grade 0 (pre- or post-ulcerative site that has
Regular margins Typically punched-out appearance, healed), grade 1 (superficial wound not involving tendon,
irregular margins capsule or bone), grade  2 (wound penetrating to tendon
Often located on plantar Commonly located on toes or capsule) and grade 3 (wound penetrating bone or joint).
surface of foot Within each Texas wound grade there are four stages
Presence of calluses Calluses absent or infrequent (Ho et al, 2013):
w Stage A—clean wounds that are not infected and non-
Loss of sensation, reflexes and Variable sensory findings
ischaemic
vibration
w Stage B—ulcers that are infected but not ischaemic
Increase in blood flow Decrease in blood flow w Stage C—ulcers that are ischaemic but not infected
(AV shunting)
w Stage D—ulcers that are both infected and ischaemic.
Dilated veins Collapsed veins Increasing stage, regardless of grade, is associated with
Dry, warm foot Cold foot increased risk of amputation and prolonged healing time.
Bony deformities Possibly no bony deformities
SINBAD system
Red appearance Pale, cyanotic The SINBAD classification tool (see Table  3) is a simple
Source: Norgren et al, 2007 score based on the site, ischemia, neuropathy, bacterial
infection and depth (SINBAD) of the primary diabetic
foot ulcer (DFU). The SINBAD study revealed that
Table 2. Putting Feet First classification of active diabetic different baseline ulcer characteristics are associated with
foot problems different outcomes. It shows that these ulcer characteristics
Definition Action can be expressed in an aggregate SINBAD score, with a
score of three or more being associated with an increase in
Presence of active ulceration, Rapid referral to and management time to healing and failure to heal (Ince et al, 2008).
spreading infection, critical by a member of a multidisciplinary
ischaemia, gangrene or unex- foot team
plained hot, red, swollen foot with
DFU versus pressure ulcer
Agreed and tailored management/ The European Pressure Ulcer Advisory Panel and National
or without the presence of pain, treatment plan according
painful peripheral neuropathy, Pressure Ulcer Advisory Panel (2009) have developed
to patient needs.
acute Charcot foot a common international definition and classification
Provide written and verbal edu- system for pressure ulcers. They define a pressure ulcer
cation with emergency contact
© 2013 MA Healthcare Ltd

numbers as a localised injury to the skin and/or underlying tissue,

Referral for specialist intervention
when required
Source: Diabetes UK, 2011
usually over a bony prominence, as a result of pressure, or
pressure in combination with shear. Grading is as follows:
w Category/stage I—non-blanchable redness of intact
skin
w Category/stage II—partial thickness skin loss or blister

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 CLINICAL FOCUS

w Category/stage III—full thickness skin loss (fat visible)

Table 3. SINBAD classification tool
w Category/stage IV—full thickness tissue loss (muscle/
bone visible) Category Definition SINBAD score
w Unstageable/unclassified—full thickness skin or tissue Site Forefoot 0
loss (depth unknown)
Midfoot and hindfoot 1
w Suspected deep tissue injury (depth unknown).
Ischemia Pedal blood flow intact: at least 0
one pulse palpable
Pressure damage reporting
There is some debate over the reporting of a DFU as a Clinical evidence of reduced 1
pedal blood flow
pressure ulcer or a DFU. Although it is not within the
scope of this article, it is worth commenting that a common Neuropathy Protective sensation intact 0
cause of diabetic foot ulceration is trauma or pressure Protective sensation lost 1
from footwear or foot deformity, and a question arises Bacterial infection None 0
over whether this should then be reported and classified Present 1
as pressure damage. There is a need for robust national
Area Ulcer <1 cm2 0
guidance on this topic.
Ulcer ≥1cm2 1
Management of DFUs Depth Ulcer confined to skin and sub- 0
To manage foot problems to a successful outcome, the cutaneous tissue
clinician must follow a series of action points that will Ulcer reaching muscle, tendon 1
improve the chances of complete healing rather than risk or deeper
chronicity or amputation. Total possible 6
score
Debridement aSource: Ince et al, 2008 b
No debridement method has been shown to be more
effective than others in achieving complete ulcer healing.
In practice, the ‘gold standard’ technique for tissue
debridement in DFUs is regular, local, sharp debridement
using a scalpel and/or forceps The benefits of debridement
include (see Figure 2):
w Removal of necrotic/sloughy tissue and callus
w Reduces pressure
w Allows full inspection of the underlying tissues
w Helps drainage of secretions or pus
w Helps optimise the effectiveness of topical preparations.
Sharp debridement should be carried out by experienced Martin Turns
practitioners (e.g.  a specialist podiatrist or nurse) with
specialist training. Other methods of debridement that can
be used in diabetic foot care are maggot therapy, autolysis
and hydrosurgery (Kleopatra and Doupis, 2012). Figure 2. (a) Diabetic foot ulcer pre-debridement.
(b) Diabetic foot ulcer post-debridement.
Infection control
Diabetic patients with a foot wound should be assessed
for the presence of infection at every dressing change. The
diagnosis of diabetic foot infection is based on clinical
findings of inflammation, rather than solely the results of
culture. Wound cultures are helpful for most infections, but
are difficult to obtain in cases with cellulitis only. However,
cultures are unnecessary for clinically uninfected lesions.
While cultures obtained from superficial swabs often yield
colonising organisms, those from deep tissue specimens
are more likely to yield true pathogens and can assist in
© 2013 MA Healthcare Ltd

optimising antibiotic selection. The severity of infection

Martin Turns

should be assessed after debridement of callus and necrotic

tissue, based on its extent/depth and the presence of any
systemic findings. All patients with a severe infection require
hospitalisation, while most with a mild-to-moderate infection Figure 3. Diabetic foot ulcer with osteomyelitis toe and
can be treated as outpatients. There are no evidence-based infection requiring hospital admission.

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 CLINICAL FOCUS
Darco International Ltd
Martin Turns
Figure 4. (a)Total contact cast. (b) Offloading boot.
criteria for admission for inpatient therapy, but deep, spreading
infection, fever and abnormal white blood cells should raise
suspicion that admission is required. There should also be a
low threshold for admission in infections when peripheral
arterial disease is present, especially if osteomyelitis is suspected.
Clinically uninfected skin wounds do not require
antimicrobial therapy. For mild-to-moderate infections,
1–2  weeks of treatment is usually effective. More serious
soft tissue infections may require up to 4  weeks and
osteomyelitis may require longer-term therapy. In patients
with osteomyelitis, antibiotic therapy based on culture results
of bone, as opposed to wound swabs, may lead to better
outcomes. Useful tests for osteomyelitis are probing to bone,
sequential X-rays, and MRI scans in particular. Repeat
MRI scans may be required to assess the response of the
osteomyelitis to the antibiotic therapy.
Patients with suspected osteomyelitis should be referred to
the local diabetic foot multidisciplinary team clinic (Figure 3).
Antibiotic therapy can generally be discontinued when signs
and symptoms of infection have resolved, even if the wound
has not healed (Lipsky et al, 2012).
Offloading of the ulcer
The total contact cast (TCC) is the preferred treatment for
non-infected, neuropathic diabetic plantar forefoot ulcers in
patients with no signs of critical limb ischemia. Adverse effects
of TCC include immobilisation of the ankle, reduced activity
level, difficulty with sleeping or driving a car and pressure
ulcers due to poor casting technique.
If casting is not available, removable walkers should be
considered. These walkers should be made irremovable as
this ‘forced adherence’ increases healing rates.The use of half-
shoes or cast shoes for neuropathic plantar ulcer treatment is
recommended if TCC or below-knee removable walkers are
contraindicated or cannot be tolerated by the patient.
If other forms of biomechanical relief are not available, then
felted foam in combination with appropriate footwear can be
used to provide some accommodative offloading at an ulcer
site (Figure  4a). Conventional or standard therapeutic shoes
should not be used for treatment of plantar foot ulcers, as
there are many devices available that are more effective (Bus
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et al, 2008) (Figure  4b). All DFUs should be considered for
offloading at the earliest possible opportunity.
Ischaemic ulcers
If peripheral arterial disease of sufficient severity to impair
wound healing is identified, revascularisation should be
considered. Exceptions to this general rule may include
severely frail patients or patients with a short life expectancy
(less than 6–12 months); patients with pre-existing severe
functional impairment unlikely to be significantly worsened
by an amputation; and patients who have such a large volume
of tissue necrosis that the foot is functionally unsalvageable
(Schaper et al, 2012). These exceptions may result in wounds
becoming chronic and non-healing.
The treatment of peripheral arterial disease should be part of
a comprehensive care plan which should also include treatment
of infection, frequent debridement (if deemed appropriate by
a skilled specialist clinician), biomechanical offloading, blood
glucose control and treatment of comorbidities. All patients
should receive aggressive cardiovascular risk management that
should include support for cessation of smoking, treatment of
hypertension and prescription of a statin as well as low-dose
aspirin or clopidogel (Schaper et al, 2012).
Local ulcer care
Clinicians should base dressing selections on the wound’s
location, size, depth, amount of exudate, presence of infection
or necrosis and the condition of the surrounding tissue.
Currently, there is insufficient evidence to recommend one
specific dressing type over another (Lipsky et al, 2012).
Dressings that can help to manage wound exudate optimally
and promote a balanced environment are key to improving
outcomes. However, a dressing that may be ideal for wounds
of other aetiologies may be entirely inappropriate for certain
DFUs. The dressing selected may have a considerable effect
on outcome and, due to the varying complexities of DFUs,
there is no single dressing to suit all scenarios. In the absence
of strong evidence of clinical effectiveness or cost effectiveness,
health-care professionals should use wound dressings that best
match the clinical appearance and site of the wound, as well as
patient preferences (Wounds International, 2013).
Necrotic wounds
The management of the necrotic foot requires a specific
form of care and attention. According to the International
Best Practice Guidelines (Wounds International, 2013), the
therapeutic aim in the treatment of necrotic dry wounds
is: ‘Remove devitalised tissue, do not attempt debridement
if vascular insufficiency suspected. Keep dry and refer for
vascular assessment’.
The urgent referral of necrotic wounds to the diabetic
foot multidisciplinary team is particularly important
© 2013 MA Healthcare Ltd
when vascular insufficiency is suspected. The diabetic foot
multidisciplinary team consists of diabetes physicians, vascular
and orthopaedic surgeons, podiatrists, diabetes nurses, tissue
viability nurses or vascular nurse specialists. They have the
collective expertise to manage these challenging wounds
effectively (NICE, 2011).
Wound Care, December 2013

Amputation
If an amputation is to be considered, the surgeon will aim to
remove all devitalised/infective tissue while maintaining the
ability of the patient to rehabilitate fully.
Education
Patient foot care education
Patient education should be an integral part of management
and prevention.Treatment outcomes will be directly influenced
by patients’ knowledge of their own medical status, their ability
to care for their wound and concordance with their treatment
It is vital that patients should know who to contact if a DFU
develops or recurs, including emergency numbers for the
foot care teams and out-of-hours contact details if available.
Educating people with diabetes regarding the need to look
after their feet improves foot care knowledge and behaviour
in the short term. However, there is insufficient evidence that
education alone, without any additional preventive measures,
effectively reduces the occurrence of ulcers and amputations.
It is essential to evaluate whether the patient has understood
the messages, is motivated to act and has sufficient self-care
skills (Wounds International, 2013).
Education of health-care professionals
Education of health-care professionals should be based on the
TRIEPodD-UK (2012) podiatry competency framework for
integrated diabetic foot care. This was developed in response
to the need to identify and standardise clinical competencies
in diabetic foot care, from clinical practice through to research
and leadership. TRIEPodD-UK recognise that podiatrists
and podiatry assistants are key health-care professionals in
the delivery, monitoring and design of diabetic foot care
services, and are increasingly leading these services in the UK.
However, reliance on the podiatry workforce alone for the
management of all levels of foot care for people with diabetes
has been suggested to be unsustainable (Diabetes UK, 2011;
NHS Diabetes, 2012).Therefore, skill-mixing (dictated by the
risk-based needs of the population with diabetes) may enable
an increase in capacity and improved care.
Conclusion
The available data to support the use of the different dressings
and adjunctive measures for the management of diabetic foot
wounds are weak. The fundamental problem with studies
supporting the benefits of various measures is that they are
small in size and suboptimal in design and execution. In light
of the complex pathophysiology of diabetic foot wounds,
most are unlikely to be healed by any single treatment. This
makes it difficult to demonstrate the effectiveness of any
one intervention in studies that measure wound healing as
the primary endpoint. Extensive clinical experience and a
few studies support several basic principles for managing
© 2013 MA Healthcare Ltd
diabetic foot wounds, often called ‘standard/good wound
care’ (Lipsky et al, 2012). These include sharp debridement
of callus and other wound debris or eschar, moist wound
healing and pressure or weight displacement from the affected
area. Other factors that are important in healing a wound
include ensuring adequate arterial perfusion to the site and
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CLINICAL FOCUS
KEY POINTS
w The urgent referral of necrotic wounds or wounds affected by
osteomyelitis to the diabetic foot multidisciplinary team is particularly
important when vascular insufficiency is suspected
w The treatment of peripheral arterial disease should be part of a
comprehensive care plan which should also include treatment of infection,
frequent debridement (if deemed appropriate), biomechanical offloading,
blood glucose control and treatment of comorbidities
w Severity of infection should be assessed after debridement of callus and
necrotic tissue, based on extent/depth and the presence of systemic findings
w The ‘gold standard’ technique for tissue debridement in diabetic foot
ulcers is regular, local, sharp debridement using a scalpel and/or forceps
w Poor clinical outcomes are generally associated with infection, peripheral
arterial disease and increasing wound depth
controlling any concomitant infection (Lipsky, 2012).
There is evidence that rapid access to multidisciplinary
foot care teams can lead to faster healing, fewer amputations,
improved survival and savings to the NHS that can substantially
exceed the cost of the team (NHS Diabetes, 2012). BJCN
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