Background

Diabetic foot ulcers, as shown in the images below, occur as a result of various factors, such as mechanical changes in conformation of the bony architecture of the foot, peripheral neuropathy, and atherosclerotic peripheral arterial disease, all of which occur with higher frequency and intensity in the diabetic population.

Diabetic ulcer of the medial aspect of left first toe before and

after appropriate wound care. associated with mild cellulitis.

Diabetic ulcer of left fourth toe

Nonenzymatic glycosylation predisposes ligaments to stiffness. Neuropathy causes loss of protective sensation and loss of coordination of muscle groups in the foot and leg, both of which increase mechanical stresses during ambulation. (See Pathophysiology and Etiology.) Diabetic foot lesions are responsible for more hospitalizations than any other complication of diabetes. Diabetes is the leading cause of nontraumatic lower extremity amputations in the United States, with approximately 5% of diabetics developing foot ulcers each year and 1% requiring amputation. (See Epidemiology.) Physical examination of the extremity having a diabetic ulcer can be divided into examination of the ulcer and the general condition of the extremity, assessment of the possibility of vascular insufficiency,[1] and assessment for the possibility of peripheral neuropathy. (See Clinical Presentation.) The staging of diabetic foot wounds is based on the depth of soft tissue and osseous involvement.[2, 3, 4] A complete blood cell count should be done, along with assessment of serum glucose, glycohemoglobin, and creatinine levels. (See Workup.) A vascular surgeon and/or podiatric surgeon should evaluate all patients with diabetic foot ulcers so as to determine the need for debridement, revisional surgery on bony architecture, vascular reconstruction, or soft tissue coverage. (See Treatment and Management.) Cilostazol is contraindicated in patients with congestive heart failure. See Medication regarding the product's black box warning. For more information, see Diabetes Mellitus, Type 1 and Diabetes Mellitus, Type 2.

deficiency of myoinositol-altering myelin synthesis and diminishing sodium-potassium adenine triphosphatase (ATPase) activity. metatarsal deformities. Underlying digital artery disease. These factors. arteriolar hyalinosis. Diabetes-related atherosclerosis Overall. causing edema of nerve trunks. further stress. Calcification and thickening of the arterial media (Mönckeberg sclerosis) are also noted with higher frequency in the diabetic population. as depicted in the image below. and effects of increased sorbitol and fructose. such as hammertoes. although whether these factors have any impact on the circulatory status is unclear. However. . elevated plasma fibrinogen levels. and eventual tissue breakdown. combined with poor arterial inflow. when compounded by an infected ulcer in close proximity. or damage from a blunt or sharp object inadvertently left in the shoe may cause blistering and ulceration. may result in complete loss of digital collaterals and precipitate gangrene. elevated plasma von Willebrand factor. structural foot deformity. confer a high risk of limb loss on the patient with diabetes. and endothelial proliferation. and increased platelet adhesiveness. Unnoticed excessive heat or cold.Pathophysiology Atherosclerosis and peripheral neuropathy occur with increased frequency in persons with diabetes mellitus (DM). pressure from a poorly fitting shoe. people with diabetes mellitus (DM) have a higher incidence of atherosclerosis.[5] The result of loss of sensation in the foot is repetitive stress. or Charcot foot (see the image below). unnoticed injuries and fractures. The reason for the prevalence of this form of arterial disease in diabetic persons is thought to result from a number of metabolic abnormalities. may develop atherosclerotic disease of largesized and medium-sized arteries. chronic hyperosmolarity. Diabetic peripheral neuropathy The pathophysiology of diabetic peripheral neuropathy is multifactorial and is thought to result from vascular disease occluding the vasa nervorum. including high low-density lipoprotein (LDL) and very-low-density lipoprotein (VLDL) levels. like people who are not diabetic. Diabetic persons. significant atherosclerotic disease of the infrapopliteal segments is particularly common in the diabetic population. endothelial dysfunction. bunions. inhibition of prostacyclin synthesis. such as aortoiliac and femoropopliteal atherosclerosis. thickening of capillary basement membranes.

compounds this trauma. The result is a convex foot with a rocker-bottom appearance. particularly the medial aspect of the navicular bone and the inferior aspect of the cuboid bone. affecting about 2% of diabetic persons. please go to the main article by clicking here. every year approximately 5% of diabetics develop foot ulcers and 1% require amputation. Age distribution for diabetic ulcers .[9] Diabetic peripheral neuropathy. causing displacement of the ankle mortise and ulceration. confers the greatest risk of foot ulceration. ulceration may occur at pressure points. Charcot foot Sensory neuropathy involving the feet may lead to unrecognized episodes of trauma due to illfitting shoes. an estimated 16 million Americans are known to have diabetes. In fact. This is termed a Charcot foot (neuropathic osteoarthropathy) and most commonly is observed in diabetes mellitus. diabetes is the leading cause of nontraumatic lower extremity amputations in the United States. and 12-24% of individuals with a foot ulcer require amputation. If a Charcot foot is neglected. Sinus tracts progress from the ulcerations into the deeper planes of the foot and into the bone. microvascular disease and suboptimal glycemic control contribute. Multiple fractures are unnoticed until bone and joint deformities become marked. Epidemiology According to the National Institute of Diabetes and Digestive and Kidney Diseases. Motor neuropathy.[7] pressure. Among patients with diabetes. which can lead to the need for amputation. To see complete information on Diabetic Neuropathy.Charcot deformity with mal perforans ulcer of plantar midfoot. Etiology The etiologies of diabetic ulceration include neuropathy.[8] and foot deformity. Charcot change can also affect the ankle. Diabetic foot lesions are responsible for more hospitalizations than any other complication of diabetes. 15% develop a foot ulcer. Indeed. causing intrinsic muscle weakness and splaying of the foot on weight bearing.[6] arterial disease. present in 60% of diabetic persons and 80% of diabetic persons with foot ulcers. and millions more are considered to be at risk for developing the disease.

the recurrence rate is 66% and the amputation rate rises to 12%. Of these. For excellent patient education resources. To see complete information on Diabetic Foot. 10% have type 1 diabetes and are usually diagnosed when they are younger than 40 years. control of hyperlipidemia. avoidance of cigarette smoking. diabetic foot deformity and ulceration occur sometime thereafter. and. particularly if treatment has been delayed. visit eMedicine’s Diabetes Center. . Half of all nontraumatic amputations are a result of diabetic foot complications. who tend to have the highest prevalence of diabetes in the world. and adequate glycemic control. appropriate shoes. 90% have type 2 diabetes). Among Medicare-aged adults. Patient Education The risk of foot ulceration and limb amputation in people with diabetes is lessened by patient education stressing the importance of routine preventive podiatric care.Diabetes occurs in 3-6% of Americans. Diabetic neuropathy tends to occur about 10 years after the onset of diabetes. Limb loss is a significant risk in patients with diabetic foot ulcers. therefore. in African Americans.[13] even if successful management results in healing of the foot ulcer. the prevalence of diabetes is about 10% (of these. Prognosis Mortality in people with diabetes and foot ulcers is often the result of associated large vessel arteriosclerotic disease involving the coronary or renal arteries. Prevalence of diabetic ulcers by race The issue of diabetic foot disease is of particular concern in the Latino communities of the Eastern United States. Also.[10] and in Native Americans. and the 5-year risk of needing a contralateral amputation is 50%.[11] Diabetes is the predominant etiology for nontraumatic lower extremity amputations in the United States. please go to the main article by clicking here.[12] In diabetic people with neuropathy. see eMedicine’s patient education article Diabetic Foot Care.