The etiology of diabetic foot ulceration is multifactorial involving risk factors as varied as peripheral sensory neuropathy, increased plantar pressures and micro-trauma.
In addition to these, calluses, edema and atherosclerotic peripheral arterial disease have also been identified as precursors to the development of diabetic foot ulcers.
Diabetic foot ulcers can be categorised into neuropathic ulcers and neuroischaemic ulcers.
Neuropathic ulcers occur on the plantar side of the foot under the metatarsal heads. These are caused by repetitive mechanical forces of abnormal gait which lead to the formation of callus.
If not removed, inflammatory autolysis and haematomas start developing under the callus, leading to tissue necrosis and the appearance of a blister.
Neuroischaemic ulcers are commonly found on the medial surface of the first metatarsophalangeal joint and over the lateral aspect of the fifth metatarsophalangeal joint.
This is marked by the formation of a superficial blister which further grows into a shallow ulcer with a base of sparse pale granulation tissue.
A detailed evaluation of the ulcer is required to determine the precise characteristics of the wound (size, shape, depth, base and border) and to see if it extends to any nearby tendon sheaths, joints or bones.
Signs of any underlying osteomyelitis, deep abscesses and infection should be documented and treated by the appropriate health care professional.
An assessment of neurological status can be undertaken using the Semmes-Weinstein monofilaments; a failure to perceive the pressure of a 10-g monofilament indicates the loss of protective sensation and the presence of peripheral sensory neuropathy.
Vascular assessment involves checking pedal pulses, the dorsalis pedis on the dorsum of the foot, and the posterior tibial pulses behind the medial malleolus, as well as capillary filling time.
Appropriate footwear is essential to avoid friction along the vulnerable margins of the foot, which can otherwise contribute to the formation of neuroischaemic ulcers.
The treatment and prevention of ulceration are both critical; ulcers are the primary cause of non-traumatic lower extremity amputations and many of the associated risk factors ultimately become predisposing factors for amputation.
A multidisciplinary approach is necessary to treat ulceration considering its multifaceted nature.
The first step in treatment includes proper debridement to remove all necrotic tissue, peri-wound callus and fibrous tissue that could increase the risk of infection in the ulcer. This is also helpful in promoting wound healing and contraction.
Biomechanical imbalances, such as flat feet, compound mechanical stresses by causing an uneven distribution of pressure across the feet which increases the risk of inflammation, particularly in high-stress regions.
Total contact foot orthotics such as MASS4D® relieve pressure on the at-risk areas of the foot by distributing weight more evenly along the plantar surface of the foot. This allows the ulcer to heal whilst permitting the patient to remain ambulatory during treatment.
MASS4D® also offers a special Bi-Lam cushion top cover for patients suffering from insensate foot symptoms and to protect against any unnoticed blistering or ulcerations.
A preventive podiatric care regimen should be adopted early to detect any impending foot problems in patients with diabetes. This should include a regular assessment of the lower limbs along with debridement of calluses and tissues.
The use of therapeutic shoes with pressure-relieving orthotics can help significantly reduce the development of diabetic foot ulcers by properly distributing weight along the plantar surface of the foot and maintaining joint range of motion.
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Repetitive plantarflexion can lead to pain and mechanical limitation in the posterior ankle joint which is known as posterior ankle impingement syndrome. This pathology commonly occurs in ballet dancers and football players.