75 Int J Diab Dev Ctries | April-June 2010 | Volume 30 | Issue 2

KEY WORDS: Neuropathy, peripheral vascular

disease, infected foot, deformed foot
DOI: 10.4103/0973-3930.62596
Corresopondence to: Dr. Sharad P. Pendsey,
Diabetes Clinic & Research Center, Shreeniwas, Opp. Dhantoli Park,
Nagpur 440 012, India. E-mail: [email protected]
Manuscript received: 28.01.2010; Revision accepted: 04.03.2010
REVIEW ARTICLE
Understanding diabetic foot
Sharad P. Pendsey
Diabetes Clinic and Research Center, Shreeniwas, Opp. Dhantoli Park, Nagpur - 440 012, India
neuroischemic, and purely ischemic lesions in diabetics
is 54, 34, and 10%, respectively.
[3]
In India, it is estimated
that approximately 40,000 legs are being amputated
every year, of which 75% are neuropathic with
secondary infection, which is potentially preventable.
Certain factors, such as, barefoot walking, illiteracy,
low socioeconomic status, late presentation by patients,
ignorance about diabetic foot care among primary care
physicians, and belief in the alternative systems of
medicine contribute to this high prevalence.
[4]
Pathogenesis
Diabetic foot ulcers result from the simultaneous actions
of multiple contributing causes. The major underlying
causes are noted to be peripheral neuropathy and
ischemia from peripheral vascular disease.
Neuropathy
Neuropathy in diabetic patients is manifested in the
motor, autonomic, and sensory components of the
nervous system.
[7]
Damage to the innervations of the
intrinsic foot muscles leads to an imbalance between
fexion and extension of the afected foot. This produces
anatomic foot deformities that create abnormal bony
prominences and pressure points, which gradually cause
skin breakdown and ulceration.
Autonomic neuropathy leads to diminished sweating.
The overlying skin becomes dry and increasingly
susceptible to fssures and a subsequent development
of infection.
The loss of sensation as a part of peripheral neuropathy
exacerbates the development of ulcerations. As trauma
occurs at the afected site, patients are unable to detect
the insult to their lower extremities. As a result, many
wounds go unnoticed and progressively worsen as the
afected area is continuously subjected to repetitive
pressure and shear forces from ambulation and weight
bearing. Charcot arthropathy is a consequence of
Introduction
Diabetic foot is ofen quite a dreaded disability, with long
stretches of hospitalization, and impossible, mounting
expenses, with the ever dangling end result of an
amputated limb. The phantom limb plays its own cruel
joke on the already demoralized psyche. The diabetic
foot, no wonder, is one of the most feared complications
of diabetes.
Diabetic foot is characterized by a classical triad of
neuropathy, ischemia, and infection.
Preventing the diabetic foot should be the frst priority.
This can be achieved by identifying the high-risk
individuals, like those with peripheral neuropathy,
peripheral vascular disease, foot deformities, and
presence of callus.
Epidemiology
Diabetic foot ulcers are common and estimated to afect
15% of all diabetic individuals during their lifetime.
It is now appreciated that 15 20% of patients with
such foot ulcers go on to need an amputation. Almost
85% of the amputations are preceded by diabetic foot
ulcers.
[1-3]
Numerous risk factors for the development of
foot ulcers have been suggested, the most important being
peripheral sensory neuropathy followed by peripheral
vascular disease. The proportion of neuropathic,
76 Int J Diab Dev Ctries | April-June 2010 | Volume 30 | Issue 2
Pendsey: Understanding diabetic foot
peripheral neuropathy. It is the result of a combination
of motor, autonomic, and sensory neuropathies, in which
there is muscle and joint laxity that leads to changes
in the arches of the feet. Furthermore, the autonomic
denervation leads to bone demineralization via the
impairment of the vascular smooth muscle, which
leads to an increase in blood fow to the bone with
consequential osteolysis.
[8]
Peripheral vascular disease
Although atherosclerosis in patients with diabetes is
similar to that seen in nondiabetics, it is generalized,
occurs prematurely and progresses at an accelerated
pace. Coronary artery, cerebrovascular, and peripheral
vascul ar di sease (PVD) are t he predomi nant
manifestations of macrovascular disease in diabetes. A
majority of patients with PVD have associated coronary
artery disease, however, the opposite is not true.
[2]
Peripheral vascular disease is found at all levels of the
arterial tree but atheroma has an apparent predilection
for certain sites, namely at bifurcations and bends in the
artery, where hemodynamic shear stress is low or fow
separation occurs. In the lower limb the common sites
are the aortoiliac segment and the superfcial femoral
artery (SFA) in the adductor canal. In diabetics more
distal vessels below the trifurcation such as the peroneal,
anterior, and posterior tibials are commonly involved.
Surprisingly foot vessels such as the dorsalis pedis are
ofen spared.
[2]

Foot infection
Infection in a diabetic foot is a limb threatening condition
because the consequences of deep infection in a diabetic
foot are more disastrous than elsewhere mainly because
of certain anatomical peculiarities. The foot has several
compartments, which are inter-communicating and the
infection can spread from one into another, and lack of
pain allows the patient to continue ambulation further
facilitating the spread. The foot also has sof tissues,
which cannot resist infection, like plantar aponeurosis,
tendons, muscle sheaths, and fascia. A combination of
neuropathy, ischemia, and hyperglycemia worsens the
situation by reducing the defense mechanism.
[2]
Osteomyelitis
Osteomyelitis generally results from a contiguous spread
of deep sof tissue infection through the cortex to the
bone marrow. A majority of deep, longstanding foot
infections are associated with osteomyelitis. Diagnosing
osteomyelitis in a patient with diabetic foot is ofen
difcult. Major problems include diferentiating sof
tissue infection from bone infection and infections
from non-infectious disorders (Charcot Foot). Plain
radiography usually shows focal osteopenia, cortical
erosions or periosteal reaction in the early stage and
sequestration in the late stage. A simple clinical test is
probing to the bone. A sterile metal probe is inserted into
the ulcer if it penetrates to the bone it almost confrms
the diagnosis of osteomyelitis. Chronic discharging
sinus and sausage-like appearance of the toe are the
clinical markers of osteomyelitis. Defnitive diagnosis
requires obtaining a bone biopsy for microbial culture
and histopathology.
The newer imaging techniques are nuclear bone scan,
computerized tomography scan (CT), positron emission
tomography (PET), and magnetic resonance imaging
(MRI). Of these, MRI is more sensitive and specifc.
[9]
Classifcation
Diabetic foot is classifed into two major types.
1. The Neuropathic Foot where neuropathy dominates
2. The Neuroischemic Foot, where occlusive vascular
disease is the main factor, although neuropathy is
present.
Neuropathy leads to fissures, bullae, neuropathic
(Charcot) joint, neuropathic edema, and digital necrosis.
Ischemia leads to pain at rest, ulceration on foot margins,
digital necrosis, and gangrene. Diferentiating between
these entities is essential because their complications
are different and they require different therapeutic
strategies.
[10]
The University of Texas Wound Classifcation System is
the most acceptable classifcation. [Table 1].
[11]
The older classification, suggested by Wagner,
[12]

Table 1: Wound classifcation system
[11]
Stages Description
Stage A No infection or ischemia
Stage B Infection present
Stage C Ischemia present
Stage D Infection and ischemia present
Grading
Grade 0 Epithelialized wound
Grade 1 Superfcial wound
Grade 2 Wound penetrates to tendon or capsule
Grade 3 Wound penetrates to bone or joint
77 Int J Diab Dev Ctries | April-June 2010 | Volume 30 | Issue 2
Pendsey: Understanding diabetic foot
accounts only for wound depth and appearance and
does not consider the presence of ischemia or infection.
Examination of feet
Examination of the feet is an integral part of the physical
examination of every patient, more so a diabetic patient.
One should look for neuropathic changes like dry skin,
fssures, deformities, callus, abnormal shape of foot,
ulceration, prominent veins, and nail lesions. Careful
atention should be given to the interdigital spaces.
Signifcant ischemia is characterized by loss of hair
on the dorsum of the foot and a dependent rubor. One
should feel the foot for warmth or coldness; examine the
peripheral pulsations such as dorsalis pedis, which can
be felt lateral to the exensor hallucis longus tendon and
posterior tibial, which is above and behind the medial
malleolus. The femoral artery should also be palpated
and auscultated for the presence of bruit. The plantar
aspects of the feet should be felt for the presence of any
bony prominence or callus.
Sensory neuropathy can be tested by using monoflaments
and biothesiometry. If these are not available, the
detection of light touch by coton wool, pinprick, and
vibration sense using a 128 Hz tuning fork is sufcient.
The goal is to detect whether the patient has lost
protective sensations (LOPS), rendering him susceptible
to foot ulceration.
A hand-held Doppler can be used to confirm the
presence of pulses and to quantify the vascular supply.
When used together with a sphygmomanometer, the
ankle and brachial systolic pressures can be measured
and the ratio then calculated. In normal subjects, the
ankle systolic pressure is higher than the brachial
systolic pressure. The normal ABI > 1, in the presence of
ischemia it is < 0.9. Absent or feeble pulses, with ABI <
0.9, confrm ischemia. Conversely, the presence of pulses
and ABI > 1 rules out signifcant ischemia.
[2]
Management
Diabetic foot should be managed using a multidisciplinary
team approach.
The management of diabetic foot ulcers includes
several facets of care. Ofoading and debridement are
considered vital to the healing process, for diabetic foot
wounds.
[13]
The goal of ofoading is to redistribute force
from the ulcers sites and pressure points at risk, to a
wider area of contact. There are multiple methods of
pressure relief, including total contact casting, half shoes,
removable cast walkers, wheelchairs, and crutches.
[14]
An open diabetic foot ulcer may require debridement if
necrotic or unhealthy tissue is present. The debridement
of the wound will include the removal of the surrounding
callus, which decreases the pressure points at the callused
sites on the foot. Additionally, the removal of unhealthy
tissue can aid in removing colonizing bacteria in the
wound. It will also facilitate the collection of appropriate
specimens for culture and permit examination for the
involvement of deep tissues in the ulceration.
[15]
Infection in a diabetic foot is limb threatening and at
times life threatening, and therefore, must be treated
aggressively. Superfcial infections should be treated
with debridement, oral antibiotics, and regular
dressings. Deep infections are considered when the
signs of infection are combined with evidence of
involvement of deeper tissue structures such as bones,
tendons or muscles. Although superfcial infections
are usually caused by gram-positive bacteria, the deep
foot infections are invariably polymicrobial and caused
by gram-positive bacteria, gram-negative bacteria,
and anaerobes. All patients with deep infections
should be hospitalized and started on broad-spectrum
antibiotics.
[16]
The choice of antibiotics initially should
be empirical, but once the culture reports are known,
it should be specific and narrowed down. Surgical
debridement should be carried out, which should
include all the devitalized tissues, sloughed tendons,
and infected bones.
Multiple injections of insulin or continuous insulin
infusion should be instituted to achieve metabolic
control.
Dressing material
The selection of wound dressings is also an important
component of diabetic wound care management. Saline-
soaked gauze dressings, for example, are inexpensive,
well-tolerated, and contribute to an atraumatic, moist
wound environment.
A wide variety of new dressing materials have been
developed.
Some of the newer dressings are film dressing,
foam dressing, non-adherent dressings, hydrogels,
hydrocolloids, and alginates.
78 Int J Diab Dev Ctries | April-June 2010 | Volume 30 | Issue 2
Pendsey: Understanding diabetic foot
The treating foot care team has to make an appropriate
choice of dressing for a particular type of wound.
[17,18]
A number of adjunctive wound care treatments are
under investigation and in practice for treating diabetic
foot ulcers. The use of human skin equivalents has been
shown to promote wound healing in diabetic ulcers via
the action of cytokines and dermal matrix components
that stimulate tissue growth and wound closure.
[19,20]

A recombinant platelet-derived growth factor is also
currently in use and has been shown to stimulate
wound healing. It is a recombinant human PDGF-BB gel
preparation, which is used for non-infected neuropathic
ulcers. It is spread over the wound and covered with non-
adherent, saline-soaked gauze dressing. The dressing is
changed once or twice every day. It has to be realized
that this gel therapy is efective only if other modalities
such as recurrent surgical debridement of the ulcer and
ofoading are adhered to.
[21]
Revascularization
Patients with evident peripheral ischemia need
revascularization as adequate arterial blood supply is
necessary to facilitate wound healing and resolve the
underlying infection.
Surgical bypass is a common method of treatment for
ischemic limbs, and favorable long-term results have
been reported. Up to a 90% 10-year limb salvage rate has
been demonstrated with surgical bypass procedures of
the lower extremity.
[22,23]
In cases where there are multiple
levels of occlusion, revascularization at each point is
necessary to restore the arterial blood fow and increase
the chance for limb salvage. Transluminal angioplasty of
the iliac arteries in conjunction with a surgical bypass in
the distal extremity may be implemented, and efcacy
has been demonstrated in diabetic patients.
[22]
Transluminal angioplasty is also an excellent option for
single stenotic lesions.
For multiple lesions or occlusions > 15 cm or occlusion
of infra-popliteal vessels, bypass surgery is the best
option.
[24]
Prevention
Early detection of potential risk factors for ulceration
can decrease the frequency of wound development. It
is recommended that all patients with diabetes undergo
a foot examination at least annually, to determine the
predisposing conditions to ulceration.
Patients should be educated regarding the importance of
maintaining good glycemic control, wearing appropriate
footwear, avoiding trauma, and performing frequent
self-examinations.
Prevention of diabetic foot includes:
1. Primary prevention: Screening of high risk feet and
proper advice on preventive footwear
2. Secondary prevention: Management of trivial foot
lesions such as callus removal, treatment of nail
pathologies, deroofng blisters, and so on.
3. Tertiary prevention: Prompt referral to a specialist
for advanced foot lesions.
[4]
Signifcant limb salvage and prevention of amputation
is achieved by training of primary care physicians and
their paramedics in diabetic foot care. The Step by Step
Project of improving diabetic foot care was recently
executed by the author under the auspices of the World
Diabetes Foundation.
[4]

Patient education and lifelong surveillance are essential
to protect feet at risk from ulceration. Patients need to
realize that high risk feet need to be used sparingly. The
activity level should be as minimal as possible.
Understanding the diabetic foot, proper examination of
feet, investigations to classify the foot ulcers, and proper
management techniques using a team approach, along
with preventive steps, would go a long way in limb
salvage and prevention of limb amputation in people
with diabetes.
Acknowledgments
I acknowledge the contribution of Dr. Rutuja Sharma for
assisting me in the preparation of the manuscript.
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Source of Support: Nil, Confict of Interest: None declared
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