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A 57-year-old man with type 2 diabetes presented with history of a neuropathic ulceration to the right foot for 2 weeks (Figure 211-1). The patient recalled having a callus for several months. He noticed blood on his sock 3 days ago. He denied fever or chills, but his glucose has been running higher than normal. The patient demonstrated loss of protective sensation, but vascular status was intact. He was referred to a podiatrist who immediately offloaded his foot with a total contact cast. His ulcer healed in 1 month, and he was subsequently fitted with orthopedic shoes.

Figure 211-1

Neuropathic ulcer under the third metatarsal head of the right foot in a patient with diabetes. Note the red base with a white rim of hyperkeratotic tissue, a classical finding of this type of ulcer. (Courtesy of Javier La Fontaine, DPM.)

Foot complications in patients with diabetes mellitus are common, costly, and impact quality of life. Neuropathic ulcers can lead to the most devastating outcome, which is an amputation. Eighty-five percent of all amputations related to diabetes are preceded by an ulcer. Prevention, early recognition, and treatment of foot ulcers are critical in avoiding amputations.

  • Of people with diabetes, 15% will experience a foot ulcer during their lifetime, and 15% of these will have osteomyelitis.1
  • Neuropathy causes approximately 50% of diabetic foot ulcers.2
  • The prevalence of neuropathic ulcer is 20% in patients with diabetic neuropathy.

  • Peripheral neuropathy is an important factor in the development of a diabetic foot ulcer.
  • Neuropathy causes autonomic denervation of precapillary arterioles, leading to persistent vasodilation and chronic edema.
  • Moderate pressure with repetitive trauma occurs in a particular site, often from poorly fitting footwear, which then leads to ulceration.

  • Diabetic neuropathy increases the risk of developing a foot ulcer by 70%.3
  • Patients with pedal deformity combined with diabetic neuropathy are 12 times more likely to develop a foot ulcer.3
  • Limited joint mobility, high level of activity, and poorly fitting footwear also increase the risk of the repetitive trauma that leads to ulceration.

The diagnosis of neuropathic ulceration is made clinically.

Clinical Features

Figure 211-2

Neuropathic ulcers in the plantar aspect of both feet. Multiple amputations in this patient caused increased pressure in different areas of the feet, which, in combination with neuropathy, led to new ulcerations. (Courtesy of Richard P. Usatine, MD.)

Typical Distribution

  • Foot ulcers are most common under the metatarsal heads, hallux, heel, or other weight-bearing areas.
  • Foot ulcers can develop ...

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