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The neuropathic diabetic foot

Nature Clinical Practice Endocrinology & Metabolism volume 3, pages 14–25 (2007)Cite this article

Abstract

Diabetic foot problems are common throughout the world, and result in major medical, social and economic consequences for the patients, their families, and society. Foot ulcers are likely to be of neuropathic origin and, therefore, are eminently preventable. Individuals with the greatest risk of ulceration can easily be identified by careful clinical examination of their feet: education and frequent follow-up is indicated for these patients. When infection complicates a foot ulcer, the combination can be limb-threatening, or life-threatening. Infection is defined clinically, but wound cultures assist in identification of causative pathogens. Tissue specimens are strongly preferred to wound swabs for wound cultures. Antimicrobial therapy should be guided by culture results, and although such therapy may cure the infection, it does not heal the wound. Alleviation of the mechanical load on ulcers (offloading) should always be a part of treatment. Plantar neuropathic ulcers typically heal in 6 weeks with nonremovable casts, because pressure at the ulcer site is mitigated and compliance is enforced. The success of other approaches to offloading similarly depends on the patient's adherence to the strategy used for pressure relief.

Key Points

  • Diabetic foot problems result in major medical, social, and economic consequences for patients, their families, and society

  • Neuropathy is the major contributory factor in the pathogenesis of diabetic foot ulcers

  • Removing pressure from the diabetic neuropathic plantar ulcer is a major part of management of such ulcers

  • Repetitive pressure on the wound, permitted because of trauma or insensitivity, may be a major contributory factor in persistence of diabetic foot ulcers

  • The presence of unilateral heat and swelling in the feet of a neuropathic diabetic patient should be presumed to be caused by acute Charcot's neuropathy until proven otherwise

  • All patients with diabetes should have a thorough foot examination at least annually

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Figure 1: Treatment plan for management of a plantar ulcer that is not limb-threatening, in a patient with diabetes and neuropathy.
Figure 2: Different types of casts.

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  1. HM Rathur is a Clinical Research Fellow in the Academic Department of Medicine, and AJM Boulton is Professor of Medicine, at the University of Manchester, Manchester, UK.,

    Haris M Rathur & Andrew JM Boulton

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Correspondence to Haris M Rathur.

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Rathur, H., Boulton, A. The neuropathic diabetic foot. Nat Rev Endocrinol 3, 14–25 (2007). https://doi.org/10.1038/ncpendmet0347

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