Intended for healthcare professionals

Clinical Review ABC of diabetes

The diabetic foot

BMJ 2003; 326 doi: (Published 03 May 2003) Cite this as: BMJ 2003;326:977
  1. Peter J Watkins

    Foot ulceration, sepsis, and amputation are known and feared by almost every person who has diabetes diagnosed. Yet these are potentially the most preventable of all diabetic complications by the simplest techniques of education and care. If lesions do occur, the majority can be cured by immediate and energetic treatment, for which good provision must be made.

    This article is adapted from the 5th edition of the ABC of Diabetes, which is published by BMJ Books (

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    Heel ulcer

    Diabetic foot disorders

    Neuropathy and ischaemia are the principal disorders underlying foot problems. Whenever a patient presents with an active lesion, it is essential to decide at an early stage whether the foot problem is:

    Precipitating causes of foot ulceration and infection

    • Friction in ill fitting or new shoes

    • Untreated callus

    • Self treated callus

    • Foot injuries (for example, unnoticed trauma in shoes or when walking barefoot)

    • Burns (for example, excessively hot bath, hot water bottle, hot radiators, hot sand on holiday)

    • Corn plaster

    • Nail infections (paronychia)

    • Artefactual (self inflicted foot lesions are rare; occasionally failure to heal is due to this cause)

    • Heel friction in patients confined to bed

    • Foot deformities (callus, clawed toes, bunions, pes cavus, hallux rigidus, hammer toe, Charcot's foot, deformities from previous trauma or surgery, nail deformities, oedema)

    • Neuropathic with an intact circulation

    • Ischaemic with (usually) or without neuropathy (neuroischaemic foot), or

    • Critically ischaemic needing urgent attention.

    A combination of ulceration and sepsis in an ischaemic foot carries a higher risk of gangrene, and early arterial assessment and management are key to avoiding major amputation.

    Men of low socioeconomic class are most prone to diabetic foot disorders, and Asian patients least likely to get them. Many causes are avoidable.

    Patients confined to bed must have their heels elevated to avoid heel blisters and sepsis. Such wounds need weeks or months of treatment and sometimes require …

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