Diabetic Foot Ulcer Management

Key Characteristics

Diabetic neuropathy affects both somatic and autonomic nerves, not just somatic nerves, in people with diabetes 1
Peripheral sensory neuropathy is the single most common component cause for foot ulceration, found in 78% of people with diabetes with ulcerations 1
The triad of peripheral sensory neuropathy, minor trauma, and foot deformity is present in >63% of patients with diabetic foot ulcers 1

The forefoot is the most common location for diabetic foot ulcers, not the heel, due to increased pressure on metatarsal heads 4
Ill-fitting shoes are the most frequent cause of ulceration, even in patients with 'pure' ischemic ulcers, highlighting the importance of proper footwear 4

The ankle-brachial index is NOT an accurate measure of the degree of ischemia in diabetic patients due to arterial calcification, according to the American Diabetes Association 2, 4
Ankle pressure might be falsely elevated because of calcification of the arteries in diabetic patients, making toe pressure measurements or transcutaneous pressure of oxygen (TcPO2) preferred tests for vascular assessment 4
Initial screening for peripheral arterial disease should include assessment of lower-extremity pulses, capillary refill time, rubor on dependency, pallor on elevation, and venous filling time, as recommended by the American College of Cardiology 2

All people with diabetes should undergo a comprehensive foot examination at least annually, according to the International Working Group on Diabetic Foot 1
The International Working Group on Diabetic Foot risk stratification system guides examination frequency, with categories ranging from very low risk to high risk, and corresponding examination frequencies 1

An interprofessional approach facilitated by a podiatrist in conjunction with other appropriate team members is recommended for individuals with foot ulcers and high-risk feet, as suggested by the American Podiatric Medical Association 2
For chronic diabetic foot ulcers that have failed to heal with optimal standard care alone, consider adjunctive treatments such as negative-pressure wound therapy, placental membranes, bioengineered skin substitutes, or autologous fibrin and leukocyte platelet patches, as recommended by the Wound Healing Society 2

Failing to assess for both neuropathic and vascular components in diabetic foot ulcers, as emphasized by the American Diabetes Association 3
Relying solely on ankle-brachial index for vascular assessment, which can be inaccurate due to arterial calcification, as noted by the American College of Cardiology 4
Failing to provide appropriate footwear for prevention of recurrence, highlighting the importance of proper footwear in diabetic foot ulcer management, as recommended by the American Podiatric Medical Association 2