Evaluation and Diagnosis of Diabetic Heel Wounds

Vascular Assessment

The American Diabetes Association recommends assessing arterial supply immediately in every diabetic foot wound patient, as peripheral artery disease (PAD) is present in 20-40% of cases and critically impacts healing and mortality 4, 3
Palpation of dorsalis pedis and posterior tibial pulses is generally adequate if both are palpable 1, 2, 5
Measurement of ankle-brachial index (ABI) and obtaining Doppler arterial waveforms is essential in all patients with foot ulcers 4, 6
An ABI of 0.9-1.3 with triphasic pedal waveforms largely excludes PAD 4, 7
Severe ischemia is indicated by an ABI <0.5 or ankle pressure <50 mmHg, requiring urgent vascular imaging and revascularization 4, 6
Arterial calcification may cause falsely elevated ABI readings, and toe pressures or TcPO2 should be used instead 1, 2, 7

The Infectious Diseases Society of America recommends testing for loss of protective sensation using 10-g monofilament at 2 of 3 sites (plantar heel, metatarsal heads, toe tips) 1, 2, 5, 8
Debridement of all hyperkeratosis (callus) and necrotic tissue is essential before assessment, except in cases of non-infected ulcers with severe ischemia 1, 2, 5, 9, 8
Infection diagnosis is made by the presence of ≥2 signs of inflammation or purulent secretions 7, 3
Infection severity should be classified as mild, moderate, or severe, with systemic signs (fever, leukocytosis) often absent in severe infections due to neuropathy 7, 3, 10

Plain radiography should be obtained in all cases to detect osteomyelitis, foreign bodies, gas in tissues, and Charcot deformity 1, 2, 7, 5
Advanced imaging, such as MRI, CT, or ultrasound, may be necessary to detect osteomyelitis, deep abscesses, sinus tracts, and muscle involvement 1, 8
Vascular imaging, including color Doppler ultrasound, CTA, MRA, or digital subtraction angiography, is necessary when revascularization is needed 4, 6

Relying solely on ABI in diabetics is not recommended, as arterial calcification causes falsely elevated readings; always correlate with pulse exam and consider toe pressures 1, 2, 7
Poor healing should not be attributed to "diabetic microangiopathy" 4, 6
Patients with PAD and infection are at high risk for major amputation and require emergency treatment 4, 6
If a wound does not improve within 6 weeks despite optimal management, consider vascular imaging and revascularization regardless of bedside test results 4, 6