Diabetic / neuropathic ulcers
This page deals primarily with the medical management of diabetic neuropathic ulcers. If you are a patient looking for more information you may wish to visit the American Association for Diabetes website* or other national associations.(*This website is not specifically endorsed by Ossur, but includes a lot of useful information.)
Diabetic/Neuropathic Ulcers
- What are the risk factors for the formation of diabetic neuropathic ulcers?
- What are the presenting characteristics of diabetic neuropathic ulcers?
- What is the accepted method of treatment of diabetic neuropathic ulcers?
- What is the average healing time for diabetic neuropathic ulcers?
- How do you know if the ulcer is infected?
- What are the three most common reasons for not healing?
- Should x-rays be taken on patients with diabetic foot ulcers?
- How do you grade a neuropathic ulcer?
- What is the best way to off-load the neuropathic ulcer?
- What type of dressing do you put on a neuropathic ulcer?
- What is the proper culture technique when culturing diabetic foot ulcers?
- What is the most appropriate antibiotic to use in infected diabetic ulcers?
- Where is the most common location for diabetic neuropathic ulcers?
What are the risk factors for the formation of diabetic neuropathic ulcers?
Peripheral neuropathy, deformity, limited range of motion, and trauma are the most common component causes in the etiology of the diabetic foot ulceration.
Other risk factors include; impaired visual acuity, history of past ulceration or amputation, obesity, autonomic neuropathy and TcPO2 levels.
Note that trauma may be defined as a long duration low pressure event, short duration high pressure event or due to repetative moderate pressure. Limited range of motion pertains to the 1st MTPJ, ankle and subtalar joints.
Deformities often include hammertoe, prominent metatarsal heads, prominent stumps from prior amputaion, hallux valgus or Charcot arthropathy.
Risk Categorization System
| Catagory | Risk Profile | Evalluation Frequency | ||||||
| 0 | No Neuropathy | Annual | ||||||
| 1 | Neropathy | Semi-anual | ||||||
| 2 | Neuropathy, PVD, and/or deformity | Quaterly | ||||||
| 3 | Neuropathy, PVD, and/or deformity | Monthly or Quaterly |
Table from the International Working Group on the Diabetic Foot. International concensus on the Diabetic foot, Amsterdam, The Netherlands, 1999
Lavery LA, Armstrong DG, Vela SA, Quebedeaux TL, Fleischli JG.
Practical criteria for screening patients at high risk for diabetic foot ulceration.
Arch Intern Med. 1998 Jan 26;158(2):157-62.
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Reiber GE, Vileikyte L, Boyko EJ, del Aguila M, Smith DG, Lavery LA, Boulton AJ.
Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings.
Diabetes Care. 1999 Jan;22(1):157-62.
PMID: 10333919 [PubMed - indexed for MEDLINE]
Reiber GE.
The epidemiology of diabetic foot problems.
Diabet Med. 1996;13 Suppl 1:S6-11. Review. No abstract available.
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Murray HJ, Young MJ, Hollis S, Boulton AJ.
The association between callus formation, high pressures and neuropathy in diabetic foot ulceration.
Diabet Med. 1996 Nov;13(11):979-82.
PMID: 8946157 [PubMed - indexed for MEDLINE]
Hill SL, Holtzman GI, Buse R.
The effects of peripheral vascular disease with osteomyelitis in the diabetic foot.
Am J Surg. 1999 Apr;177(4):282-6.
PMID: 10326843 [PubMed - indexed for MEDLINE]
Boyko EJ, Ahroni JH, Stensel V, Forsberg RC, Davignon DR, Smith DG.
A prospective study of risk factors for diabetic foot ulcer. The Seattle Diabetic Foot Study.
Diabetes Care. 1999 Jul;22(7):1036-42.
PMID: 10388963 [PubMed - indexed for MEDLINE]
Pecoraro RE, Reiber GE, Burgess EM.
Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care. 1990 May;13(5):513-21.
PMID: 2351029 [PubMed - indexed for MEDLINE]
Fernando DJ, Hutchison A, Veves A, Gokal R, Boulton AJ.
Risk factors for non-ischaemic foot ulceration in diabetic nephropathy. Diabet Med. 1991 Apr;8(3):223-5.
PMID: 1828736 [PubMed - indexed for MEDLINE]
Rosenbloom AL, Silverstein JH.
Connective tissue and joint disease in diabetes mellitus. Endocrinol Metab Clin North Am. 1996 Jun;25(2):473-83. Review.
PMID: 8799711 [PubMed - indexed for MEDLINE]
Coleman WC, Brand PW, Birke JA.
The total contact cast. A therapy for plantar ulceration on insensitive feet.
J Am Podiatry Assoc. 1984 Nov;74(11):548-52. Review. No abstract available.
PMID: 6389655 [PubMed - indexed for MEDLINE]
Han P, Ezquerro R.
Diabetic foot wound care algorithms.
J Am Podiatr Med Assoc. 2002 Jun;92(6):336-49.
PMID: 12070234 [PubMed - indexed for MEDLINE]
Abouaesha F, van Schie CH, Griffths GD, Young RJ, Boulton AJ.
Plantar tissue thickness is related to peak plantar pressure in the high-risk diabetic foot.
Diabetes Care. 2001 Jul;24(7):1270-4.
PMID: 11423514 [PubMed - indexed for MEDLINE]
Margolis DJ, Kantor J, Santanna J, Strom BL, Berlin JA.
Risk factors for delayed healing of neuropathic diabetic foot ulcers: a pooled analysis.
Arch Dermatol. 2000 Dec;136(12):1531-5.
PMID: 11115166 [PubMed - indexed for MEDLINE]
Frykberg RG, Armstrong DG, Giurini J, Edwards A, Kravette M, Kravitz S, Ross C, Stavosky J, Stuck R, Vanore J.
Diabetic foot disorders: a clinical practice guideline. American College of Foot and Ankle Surgeons.
J Foot Ankle Surg. 2000;39(5 Suppl):S1-60. Review.
PMID: 11280471 [PubMed - indexed for MEDLINE]To top
What are the presenting characteristics of diabetic neuropathic ulcers?
Diabetic ulcers are commonly found on the plantar aspect of the foot, more specifically under the metatarsal heads, and heel. Pedal pulses may or may not be present depending upon the vascular status of the patient. Initially, you may see pre-ulcerative hemorrhaging beneath a hyperkeratotic lesion. This occurs under the area of maximal pressure. This inflammatory autolysis in the subcutaneous tissue may proceed to buttonhole through the skin creating a visible ulceration. The ulcer is surrounded by hyperkeratotic tissue with a pink granulation tissue base. The ulcers tend to bleed easily and are non tender to palpation or debridement. This description corresponds to a purely neuropathic ulcer without an ischemic component.
Laing P.
The development and complications of diabetic foot ulcers.
Am J Surg. 1998 Aug;176(2A Suppl):11S-19S. Review.
PMID: 9777968 [PubMed - indexed for MEDLINE]
Brand PW. Pathomechanics of diabetic (neurotrophic) ulcer and its conservative management. In: Bergan JJ, Yao JST, eds.Gangrene and Severe Ischaemia of the Lower Extremities. New York: Grune & Stratton; 1978:185-189.
What is the accepted method of treatment of diabetic neuropathic ulcers?
As prevention is much better than a cure, treatment should begin with patient education and followed by determining the causative factor for ulceration. The patient should be reminded to keep their blood glucose under control. Debridement of all necrotic, callus, and fibrous tissue plays a fundamental role in treatment. A warm moist environment should be maintained and the most important treatment modality is to offload the ulcer site. Wounds that do not heal by these conventional methods may benefit from advanced modalities such as hyperbaric treatment, growth factors, bioengineered tissue, vacuum assisted closure (VAC), biological dressings, plastic surgery, or active topicals. Treatment of the underlying ischemia should be considered if present.
The diabetic neuropathic ulcer: an overview.
Ostomy Wound Manage. 1999 Jan;45(1A Suppl):6S-20S; quiz 21S-22S. Review.
PMID: 10085972 [PubMed - indexed for MEDLINE]
Calhoun JH, Overgaard KA, Stevens CM, Dowling JP, Mader JT.
Diabetic foot ulcers and infections: current concepts.
Adv Skin Wound Care. 2002 Jan-Feb;15(1):31-42; quiz 44-5. Review. No abstract available.
PMID: 11905449 [PubMed - indexed for MEDLINE]
Frykberg RG, Armstrong DG, Giurini J, Edwards A, Kravette M, Kravitz S, Ross C, Stavosky J, Stuck R, Vanore J.
Diabetic foot disorders: a clinical practice guideline. American College of Foot and Ankle Surgeons.
J Foot Ankle Surg. 2000;39(5 Suppl):S1-60. Review.
PMID: 11280471 [PubMed - indexed for MEDLINE]
Diagnosis and treatment of diabetic foot infections.
Baillieres Best Pract Res Clin Rheumatol. 1999 Mar;13(1):149-61. Review.
PMID: 10952854 [PubMed - indexed for MEDLINE]To top
What is the average healing time for diabetic neuropathic ulcers?
A comparative analysis of several studies done on the healing rates of DM neuropathic ulcers receiving standard care show that approximately 30% of these ulcers will heal within 20 weeks. Note that the patient's age, duration of the wound, and other risks may change these results.
Margolis DJ, Kantor J, Berlin JA.Healing of diabetic neuropathic foot ulcers receiving standard treatment. A meta-analysis.
Diabetes Care. 1999 May;22(5):692-5.
PMID: 10332667 [PubMed - indexed for MEDLINE]
WiemanJT, STniellJM,Su Y: Efficacy and safety of a topical gel formulation of recombinant human platelet-derived growth factor-BB (becaplermin) in patients with chronic neuropathic diabetic ulcers: a phase III randomized placebo-controlled double-blind study. Diabetes Care 21:822-827,1998
Jeffcoate WJ, Mactarlane RM, Fletcher EM: The description and classification of diabetic foot lesions. Diabet Med 10:676-679, 1993
Richard JL, Parer-Richard C, Daures JP, Clouet S, Vannereau D, Bringer J, Rodier M, Jacob C, Comte-Bardonnet M: Effect of topical basic fibroblast growth factor on the healing of chronic diabetic neuropathic ulcer of the foot: a pilot, randomized, double-blind, placebo-controlled study. Diabetes Care 8:64-69,1995
Gentzkow GD, lwasaki SD, Hershon KS,Mengel M, PrendergastJJ, RicottaJJ, Steed DP, Lipkin S; Use ofdermagraft, a cultured human dermis, to treat diabetic foot ulcers. Diabetes Care 19:350-354,1996
Steed DL, the Diabetic Ulcer Study Group: Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity diabetic ulcers. J Vase Surg 21:71-79, 1995
Steed DL, Goslen JB, Holloway GA, Malone JM, Bunt TJ, Webster MW: Randomized prospective double-blind trial in healing chronic diabetic foot ulcers: CT- 102 activated platelet supernatant, topical versus placebo. Diabetes Care 15:1598-1604, 1992
Steed DL, RicottaJJ, PrendergastJJ, Kaplan RJ, Webster M\V McGill JB, Schwartz SL, RGD Study Group; Promotion and acceleration of diabetic ulcer healing by arginine glycine-aspartic acid (RGD) peptide matrix. Diabetes Care 18:39-46,1995
Dermagraft Trial. Food and Drug Administration. Center for Devices & Radiological Health General & Plastic Surgery Devices Panel Meeting. Gaithersburg, MD, 19 January 1998
Becaplermin Trial 3. Food and Drug Administration. Center for Devices & Radiological Health General & Plastic Surgery Devices Panel. Bethesda.MD, 14 July 1997
Becaplermin Trial 4. Food and Drug Administration. Center for Devices & Radiological Health General & Plastic Surgery Devices Panel. Bethesda, MD, 14 July 1997
How do you know if the ulcer is infected?
The presence of pain in a normally painless neuropathic foot should help lead to the diagnosis of a deep infection. Diabetic wounds have higher prevelance of infection and severity than non diabetic wounds. Signs and symptoms of infection include, fever, chills, nausea, loss of appetite, erythema, edema, purulent exudates, foul odor, and pain. Laboratory values of an elevated white blood count, sedimentation rate and elevated neutrophils may be present in an infected diabetic foot ulceration.
Laing P.The development and complications of diabetic foot ulcers.
Am J Surg. 1998 Aug;176(2A Suppl):11S-19S. Review.
PMID: 9777968 [PubMed - indexed for MEDLINE] To top
What are the three most common reasons for not healing?
There are several reasons why diabetic and non-diabetic ulcerations are slow to heal. The three most common reasons are: 1) infection, 2) ischemia, and 3) inadequate offloading of the ulcer site. Anti-inflammatory, cytotoxic, and oral steroid medications are other contributing factors to slow or non-healing ulcerations/wounds.
Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Armstrong DG, Harkless LB, Boulton AJ.A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems.
Diabetes Care. 2001 Jan;24(1):84-8.
PMID: 11194247 [PubMed - indexed for MEDLINE]
Stadelmann WK, Digenis AG, Tobin GR.
Impediments to wound healing.
Am J Surg. 1998 Aug;176(2A Suppl):39S-47S. Review.
PMID: 9777971 [PubMed - indexed for MEDLINE]
Should x-rays be taken on patients with diabetic foot ulcers?
Plain films should be taken when an underlying bone infection is suspected or needs to be ruled out. Most clinicians take plain films during the initial visit in a patient who presents with a neuropathic ulceration in order to have baseline films. Baseline films are important because it gives the clinician something to compare to when obtaining a second or third set of films days to weeks later. Osseous changes in an osteomyelitic bone may not be present in the first 14 days of infection and therefore a second set of films should be taken two weeks later to confirm the presence or absence of osseous destruction.
Laing P.The development and complications of diabetic foot ulcers.
Am J Surg. 1998 Aug;176(2A Suppl):11S-19S. Review.
PMID: 9777968 [PubMed - indexed for MEDLINE] Lipsky BA.
Osteomyelitis of the foot in diabetic patients.
Clin Infect Dis. 1997 Dec;25(6):1318-26. Review.
PMID: 9431370 [PubMed - indexed for MEDLINE]
Keenan AM, Tindel NL, Alavi A.
Diagnosis of pedal osteomyelitis in diabetic patients using current scintigraphic techniques.
Arch Intern Med. 1989 Oct;149(10):2262-6.
PMID: 2802892 [PubMed - indexed for MEDLINE]
Croll SD, Nicholas GG, Osborne MA, Wasser TE, Jones S.
Role of magnetic resonance imaging in the diagnosis of osteomyelitis in diabetic foot infections.
J Vasc Surg. 1996 Aug;24(2):266-70.
PMID: 8752038 [PubMed - indexed for MEDLINE
McIntyre KE.
Control of infection in the diabetic foot: the role of microbiology, immunopathology, antibiotics, and guillotine amputation.
J Vasc Surg. 1987 May;5(5):787-90. Review.
PMID: 3553623 [PubMed - indexed for MEDLINE]
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How do you grade a neuropathic ulcer?
The most commonly used classifications for diabetic foot ulcers are the Wagner and the University of Texas Wound Classification System.
The Wagner Ulcer Classification system:
| Grade 1 | Superficial Diabetic Ulcer | ||
| Grade 2 | Ulcer extension: Involves ligament, tendon, joint capsule or fascia No abscess or Osteomyelitis | ||
| Grade 3 | Deep ulcer with abscess or Osteomyelitis | ||
| Grade 4 | Gangrene to portion of forefoot | ||
| Grade 5 | Extensive gangrene of foot | ||
The University of Texas Wound Classification System for Diabetic Foot Ulcers
This system assesses the depth of ulcer penetration, the presence of wound infection, and the presence of clinical signs of lower-extremity ischemia.
| Apperance of Wound | Grade | ||
| preulcerative change or post-healing | 0 | ||
| superficial wound not involving tendon joint capsule or bone | 1 | ||
| wound penetrating to tendon or joint capsule but not bone | 2 | ||
| wound penetrating to bone or into joint | 3 | ||
| Infection Status | Circulation Status | Stage |
| clean (noninfected) | nonischemic | A |
| infected | nonischemic | B |
| noninfected | ischemic | C |
| infected | ischemic | D |
Note: The chances for healing decrease with each higher Stage, the risk of amputation increases for Stages B and D but not C, and the healing time for the ulcer increases stepwise for each Stage.
Lavery LA, Armstrong DG, Harkless LB.
Classification of diabetic foot wounds.
J Foot Ankle Surg. 1996 Nov-Dec;35(6):528-31.
PMID: 8986890 [PubMed - indexed for MEDLINE
Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJ.
A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems.
Diabetes Care. 2001 Jan;24(1):84-8.
PMID: 11194247 [PubMed - indexed for MEDLINE]To top
What is the best way to off-load the neuropathic ulcer?
Total contact casting (TCC) is considered the gold standard for management of neuropathic ulcers. Other acceptable alternatives include removable walking braces, therapeutic shoes and insoles, half shoe (Darco ), Aircast diabetic walker (Aircast), or felt to foam pads with cut out areas for localized pressure relief.
Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ, Harkless LB.
Off-loading the diabetic foot wound: a randomized clinical trial.
Diabetes Care. 2001 Jun;24(6):1019-22.
PMID: 11375363 [PubMed - indexed for MEDLINE]
Coleman WC, Brand PW, Birke JA.
The total contact cast. A therapy for plantar ulceration on insensitive feet.
J Am Podiatry Assoc. 1984 Nov;74(11):548-52. Review. No abstract available.
PMID: 6389655 [PubMed - indexed for MEDLINE]
Lavery LA, Vela SA, Lavery DC, Quebedeaux TL.
Total contact casts: pressure reduction at ulcer sites and the effect on the contralateral foot.
Arch Phys Med Rehabil. 1997 Nov;78(11):1268-71.
PMID: 9365359 [PubMed - indexed for MEDLINE]
Lavery LA, Vela SA, Fleischli JG, Armstrong DG, Lavery DC.
Reducing plantar pressure in the neuropathic foot. A comparison of footwear.
Diabetes Care. 1997 Nov;20(11):1706-10.
PMID: 9353613 [PubMed - indexed for MEDLINE]
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What type of dressing do you put on a neuropathic ulcer?
All dressings for diabetic neuropathis ulcers should maintain a moist ulcer environment. This promotes the migration of fibroblasts and epithelial cells and allows the growth factors present in the serous exudate to increase healing. You may cleanse a wound that is expected to heal with a non-cytotoxic fluid like saline. Betadine is cyto toxic and will kill granulation tissue.
Dressings for diabetic ulcers are categorized by their affect on moisture in the wound environment.
For a draining ulcer: Polyurethane foams (Lyofoam, Allevyn, NudermNu-Derm, FlexanFlexzan), Alginates (Kalostat, Sorbsan), and Hydrogels (IntraSite, ElastoGel, ClearSite, Aquasorb).
For a dry ulcer: Hydrocolloid wafers (DuoDerm, Comfeel, TegabsorbTegasorb, Restore) and Thin films (OpSite, Tegaderm).
A wet to moist dressing of cotton guaze and saline is quite suitable for many neuropathic ulcers. This is another means of mechanical debridement.To top
What is the proper culture technique when culturing diabetic foot ulcers?
Superficial swab cultures have been shown to be unreliable because they don't always reflect the true microbiology present in the deep tissue. Deep culture has been most reliable and is the recommended technique after performing the debridement of the overlying necrotic tissue.
Sharp CS, Bessman AN, Wagner FW Jr, Garland D. Microbiology of deep tissue in diabetic gangrene. Diabetes Care 1978; 1:289.
Sharp CS, Bessman AN, Wagner FW Jr, Garland D, Reece E, Microbiology of superficial and deep tissues in infected diaetic gangrene. Surg Gynecol Obstet 1979;149:217.
Sapico FL, Witte, JL, Canawati HN, Mongomerie JZ, Bessman AN, The infected diabetic foot of the diabetic patient: quantitative microbiology and analysis of clinical features. Rev Infect Dis 1984;6:171
Sapico FL, Canawati HN, Witte JL, Mongomerie JZ, Wagner FW Jr. Bessman AN, Quantitative aerobic and anaerobic bacteriology of infected diabetic feet. J. Clin Microbiol 1980;12:413To top
What is the most appropriate antibiotic to use in infected diabetic ulcers?
When culture results are not readily available, clinicians should choose drugs that cover gram positive, gram negative and anaerobic organisms. Initial management of diabetic foot infections should be on the broad spectrum level. If the infection is uncomplicated then it could be treated on outpatient basis with oral agents, however if the infection is complicated then the patient should be admitted to the inpatient facility and placed on intravenous antibiotics.
Broad spectrum antibiotics on inpatient basis include the following:
Ampicillin/Sulbaclam (Unasyn), Ticarcillin/Clavulanate (Timentin), Pipercillin/Tazobaclam (Zosyn), Imipenem/Cilastatin (Primaxin), Ciprofloxacin and Clindamycin
Oral antibiotics on outpatient basis can include the following:
Amoxacillin/Clavulanate (Augmentin) Cephalosporin (Omnicef) , Levaquin and Clindamycin, Keflex
Grayson, LM, Diabetic Foot Infections, Infectious Disease Clinics of North America. 9:1, 143:161, 1995
Tan JS, File TM Jr.
Diagnosis and treatment of diabetic foot infections.
Baillieres Best Pract Res Clin Rheumatol. 1999 Mar;13(1):149-61. Review.
PMID: 10952854 [PubMed - indexed for MEDLINE]
Deery HG 2d, Sangeorzan JA. Saving the diabetic foot with special reference to the patient with chronic renal failure. Infect Dis Clin North Am 2001;15:953-81.To top
Where is the most common location for diabetic neuropathic ulcers?
Diabetic ulcers tend to occur most commonly on the plantar weight bearing surfaces of the foot underneath the pressure point. The clinician should inspect the medial aspect of the 1st MTPJ in hallux valgus deformities, the dorsal aspect of the DIPJ with mallet toe deformities, the dorsal aspect of the PIPJ and plantar corresponding sub metatarsal head with a hammertoe deformity, the distal aspect of any prominent toes, and under any prominent metatarsal heads. Limitation of range of motion and subsequent increase in shear stress and peak plantar pressures occur distal to the joint with limitation of range of motion.
Birke, JA, Franks DB, Foto, JG. First Ray Joint Limitation, Pressure and Ulceration of the First Metatarsal Head in Diabetes Mellitus. Foot and Ankle International. 16:5, 1995, 277-284.
Boyko, EJ. Ahroni, JH. Stensel, V. Forsberg, RC> Davignon, DR. Smith, D. A Prospective Study of Risk Factors for Diabetic Foot Ulcer. Diabetes Care, 22:7, 1999
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