Diabetic foot ulcersBMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7538.407 (Published 16 February 2006) Cite this as: BMJ 2006;332:407
- Michael E Edmonds, consultant physician,
- A V M Foster, chief podiatrist
- diabetic foot clinic at King's College Hospital, London
Diabetic foot ulcers can be divided into two groups: those in neuropathic feet (so called neuropathic ulcers) and those in feet with ischaemia often associated with neuropathy (so called neuroischaemic ulcers). The neuropathic foot is warm and well perfused with palpable pulses; sweating is diminished, and the skin may be dry and prone to fissuring. The neuroischaemic foot is a cool, pulseless foot; the skin is thin, shiny, and without hair. There is also atrophy of the subcutaneous tissue, and intermittent claudication and rest pain may be absent because of neuropathy.
The crucial difference between the two types of feet is the absence or presence of ischaemia. The presence of ischaemia may be confirmed by a pressure index (ankle brachial pressure index < 1). As many diabetic patients have medial arterial calcification, giving an artificially raised ankle systolic pressure, it is also important to examine the Doppler arterial waveform. The normal waveform is pulsatile with a positive forward flow in systole followed by a short reverse flow and a further forward flow in diastole, but in the presence of arterial narrowing the waveform shows a reduced forward flow and is described as “damped.”
Neuropathic foot ulcer
Neuropathic ulcers usually occur on the plantar aspect of the foot under the metatarsal heads or on the plantar aspects of the toes.