Risk Factors for Foot Ulcerations

The prevention of first and recurrent foot ulcers especially in patients with diabetes mellitus is essential to protect the individual from a host of foot complications and lower limb amputations.

High morbidity and mortality rates combined with the significant utilisation of health care resources makes the early assessment and recognition of risk factors associated with foot ulcers important.

The Eurodiale (European Study Group on Diabetes and the Lower Extremity) study, conducted across 14 European centres in 2003 to 2004, provided new insights into the intricacies involved in managing diabetic foot ulcers and how diabetic foot care could be improved.

The study identified peripheral arterial disease (PAD) and peripheral neuropathy as major risk factors in the development of diabetic foot ulcers, with the two conditions present in 86 per cent and 49 per cent of the patients assessed.

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With the high prevalence of PAD found in diabetic foot ulceration, the project concluded that patients with and without PAD should be defined as two separate disease states because the management strategy, outcome and predictors of outcome for the two conditions differ.

Zaine et al. led the largest study in Australia to investigate the classification, characteristics, location of diabetic foot ulcers and the patients’ socio-economic status; Australia is ranked ninth of 39 countries in the Western Pacific region most affected by diabetes.

In addition to the findings of the Eurodiale study, the authors also identified smoking as a strong risk factor for peripheral arterial disease as over half of the patients recruited were either smokers or ex-smokers.

Increasing age was established as a contributory intrinsic factor to chronic wounds as the skin easily damages; older cells lack the capability to proliferate as fast and have diminished response to stress.

Another interesting observation from the study was the fact that over half of all the patients were overweight and obese/morbidly obese which increases the risk of cardiac-related disease and makes offloading more difficult.

Obesity was also determined as a risk factor by Al Ayed et al. who examined foot ulcers, feet at risk and associated risk factors among diabetics by applying a cross-sectional design on 1000 diabetes patients (both type-1 and type-2) at the NCDEG, the most specialised centre for diabetic patients in Jordan.

A systematic review was conducted by van Netten et al. to investigate the effectiveness of interventions to prevent foot ulcers in persons with diabetes who are at risk for ulceration.

The study found strong evidence to support an integrated foot care regimen involving home-monitoring of foot skin temperatures with subsequent preventative actions and the use of therapeutic footwear that had a demonstrated pressure-relieving effect on the patient’s foot.

The use of therapeutic shoes with pressure-relieving orthotics can guard against the development of diabetic foot ulcers by properly distributing weight along the plantar surface of the foot and maintaining joint range of motion.

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®, with a special Bi-Lam cushion top cover, relieve pressure from 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.

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