Foot Ulcers

What are the symptoms of foot ulcers? 

The main symptoms of foot ulcers include:

• Visible open wound or sore, usually on the foot's weight-bearing areas like the ball or bottom of the foot.
• Swelling, redness, and warmth. These signs can indicate inflammation or infection.
• Pain and discomfort. While diabetic neuropathy might diminish the sensation of pain, some individuals do experience pain or discomfort around the ulcer site.
• Numbness and tingling. People with sensory neuropathy might notice numbness, tingling, or reduced sensation around the ulcer, which can delay the detection of the ulcer.

As foot and toe ulcers develop, they typically begin with alterations in the skin, such as increased dryness, scaliness, and redness, along with possible rashes. Over time, these ulcers can expand in size and depth, potentially extending down to the bone. In more severe stages, you might notice the formation of a callus with a hardened edge around the ulcer, discharge that could indicate an infection, a brownish tinge to the surrounding skin, and a noticeable foul smell.

If our doctor suspects a serious infection, they may order an X-ray to look for signs of bone infection. 

What causes foot ulcers? 

Neuropathy and numbness are prominent causes of foot ulcers, particularly in patients with diabetes, due to several interconnected factors:

• Loss of sensation: Neuropathy, especially diabetic neuropathy, often leads to a loss of sensation in the feet. This numbness means individuals may not feel minor injuries, such as cuts, blisters, or sores. Without this sensory feedback, a small wound can go unnoticed and untreated, potentially leading to an ulcer.
• Altered biomechanics: Neuropathy can also cause changes in the muscles and bones of the feet, leading to altered biomechanics. This can result in areas of high pressure when walking or standing, increasing the risk of skin breakdown and the development of ulcers, especially in areas of high pressure like the ball of the foot or under the big toe.
• Poor circulation: Diabetic patients with poor glycemic control often have poor circulation as well. Reduced blood flow can impair the healing process, making it harder for the body to heal minor wounds, leading to an increased risk of ulcers.
• Infections: Because numbness delays the detection of injuries, small cuts or blisters that might normally be treated quickly can become infected, and these infections can lead to ulcers if not promptly and adequately addressed.
• Dry and cracked skin: Neuropathy can also affect the sweat glands, leading to dry skin. Dry, cracked skin is more susceptible to wounds, which can develop into ulcers.
• Charcot foot: In some cases, diabetes-related neuropathy can lead to a condition known as Charcot foot, a serious condition that can cause deformities, dislocations, and fractures in the foot. These changes can lead to areas of increased pressure and subsequent ulcer formation.

Who's at a higher risk of developing foot ulcers?

Individuals with a higher risk of developing foot and toe ulcers primarily include those with diabetes, particularly around 15% of diabetic patients who are likely to experience an ulcer, often on the underside of the foot. The risk is elevated among people of Black, Native American, and Hispanic heritage.

Those suffering from diabetes-related complications like eye, kidney, or heart diseases are also more susceptible. Additional risk factors include having poor blood circulation, heart disease, obesity, or specific foot conditions such as bunions or hammertoes. Moreover, lifestyle choices such as tobacco and alcohol use can further increase the likelihood of such ulcers.

What are diabetic foot ulcers? 

Diabetes affects the blood vessels in the body, increasing the general risk of infection and — specifically — increasing your risk of foot ulcers.

Fundamentally, the increase in blood sugar levels severely damages blood vessels over time. Then, the patient's blood pressure goes down as blood flow to peripheral areas like the limbs worsens.

As a result, infections are more challenging to treat. Diabetic pressure ulcers are also hard to spot because the disease damages nerves and most patients don't feel the pain from these injuries. If ignored, foot ulcers can lead to gangrene — the death of tissue in the area.

Patients with diabetic foot ulcers may experience worse side effects due to diabetes complications. Because of the complications from diabetes, lower extremity amputation may be necessary to prevent the infection from spreading.

Common diabetic risk factors for amputation include peripheral neuropathy, structural foot deformity, ulceration, infection, and peripheral vascular disease. The best way to prevent amputation and preserve your quality of life is to follow up with your healthcare provider and follow their advice for proper blood glucose management and wound care.

What are venous leg ulcers?

Venous leg ulcers are open sores that typically occur on the lower leg, usually around the ankle, and are a common complication of chronic venous insufficiency. This condition arises when the veins in the legs fail to effectively return blood back to the heart, often due to damaged or weakened vein valves. The resulting poor circulation leads to increased pressure in the leg veins, especially when standing or sitting for long periods.

People suffering from conditions like deep vein thrombosis are at a greater risk of these ulcers. Other health problems like osteoarthritis, leg injuries, varicose veins, and knee and hip replacement surgeries also have greater odds of venous ulcers.

What are the treatment options for venous and diabetic foot ulcers? 

As soon as you’ve noticed symptoms of an ulcer, get to your doctor. Management of diabetic foot ulcers requires starting treatment as soon as possible to reduce the risk of infection and the need for limb amputation. The duration for the healing of an ulcer can vary, typically ranging from several weeks to a few months, provided that appropriate treatment is administered.

Your treatment plan will be individualized based on what medical condition is causing your ulcers and can include:

Offloading 

For the best healing, especially if the ulcer is on the bottom of the foot, pressure must be taken off the ulcer. Known as offloading, pressure is taken off through the use of special footwear, braces, casts, or mobility aids (such as a wheelchair or crutches).

Debridement

Debridement is the removal of calluses around the wound as well as necrotic tissue. In the case of an abscess, debridement of abscessed tissue will be required after professional drainage.

Properly dressing the wound 

Wounds and ulcers heal faster and are less likely to get infected if they’re covered and kept moist. Wound management includes topical medications ranging from saline to growth factors (medications that trigger tissue repair) as well as proper wound dressings. 

Skin substitutes and collagen-infused dressings have been shown to be very effective in the treatment of foot ulcers.

Antibiotics 

If an ulcer has become infected, we will prescribe antibiotics. The choice of antibiotic depends on several factors, including the severity of the infection, the type of bacteria involved (if known), the patient's medical history, and any allergies. 

For mild infections, oral antibiotics are usually sufficient. In cases of more severe or deep infections, intravenous (IV) antibiotics may be necessary.

Amniotic wound graft treatment for ulcers 

Amniotic grafts, derived from the amniotic membrane in placenta, are rich in growth factors, collagen, and anti-inflammatory properties. When applied to a diabetic ulcer, they act as a biological scaffold, enhancing the body’s natural healing process.

The graft’s natural composition accelerates tissue repair and reduces inflammation, which is vital for healing diabetic wounds prone to poor circulation and nerve damage. Additionally, their antimicrobial properties help prevent infections, a common risk in diabetic foot ulcers.

The process involves cleaning the ulcer and applying the graft directly onto it, promoting new tissue growth and minimizing scarring. This treatment, as part of a holistic approach including blood sugar control and regular foot care, is crucial in managing diabetic ulcers effectively.

Other advanced treatments may involve grafts with recombinant growth factors, stem cell therapy, or hyperbaric oxygen therapy.

What is diabetic foot ulcer surgery? 

Most non-infected foot ulcers don’t require surgery. However, if non-surgical treatment fails, surgical management may be necessary.

Surgical care may include shaving or excision of bone and the correction of deformities (hammertoes, bunions, bony prominences) to remove pressure from the affected area.

In the worst-case scenario, the ulcer can develop gangrene and your doctor may need to amputate the affected area.

How do you prevent diabetic foot ulcers? 

The most important preventative measure is patient education.

Proper management of type 2 diabetes and blood glucose levels not only helps promote wound healing and prevent chronic wounds, it also minimizes other risk factors that lead to diabetic foot ulcers to begin with.

 Diabetic foot care to prevent foot complications is essential. To prevent more severe foot problems you should:

• Examine feet daily, especially between the toes and the sole—for cuts, bruises, cracks, blisters, warts, corns, redness, and ulcers. Report any abnormalities to your healthcare team.
• Wash feet daily, making sure to dry the feet thoroughly and dry between the toes afterward.
• Use high-quality foot cream to prevent skin from getting dry and cracked.
• Always wear footwear to protect your feet from accidental injury.
• Cut toenails straight across to prevent ingrown toenails. Toenails can also be cut by a professional to decrease the risk of injury,
• Have a diabetic foot exam with your podiatrist every year and attend any follow-up appointments. 

UFAI, Southern California’s largest foot and ankle wound care specialists 

University Foot & Ankle Institute is nationally recognized for advanced wound care treatment far beyond what a primary care physician can provide. Our podiatrists have decades of combined foot care and wound care experience managing the special circumstances surrounding all types of foot conditions, including plantar ulcers, surgical site infections, and puncture wounds.

As one of Southern California’s largest and oldest podiatric healthcare practices, our wound care center offers multi-disciplinary medical care and diagnostic testing on-site, offering our patients convenience and peace of mind. For example, we can perform vascular testing at our clinics and have a vascular surgeon on our staff to treat patients with complex vascular diseases.

If you want to learn more about how UFAI can help you, please call (877) 736-6001 or make an appointment online now.

University Foot and Ankle Institute is conveniently located throughout Southern California and the Los Angeles area. Our foot and ankle surgeons are available at locations in or near Santa Monica, Beverly Hills, West Los Angeles, Sherman Oaks, the San Fernando Valley, El Segundo, the South Bay, LAX, Calabasas, Agoura Hills, Westlake Village, Valencia, Santa Clarita, and Santa Barbara. We accept over 1,000 PPO health insurance plans, including Medicare.

 

 

Foot ulcer FAQs

What do foot ulcers look like?

In the early stages, a foot ulcer may look like a red, shallow crater in the skin. As it progresses, it can become deeper and may expose underlying tissues, including muscles, tendons, or bones.

 

The skin around the ulcer may be red, swollen, and warm. In cases of severe infection, it may be accompanied by discharge or foul odor.

 

Are foot ulcers contagious? 

Foot and toe ulcers are not contagious. They are not transmitted between individuals, so you cannot pass them to someone else, nor can you contract them from another person.

 

References

Boulton AJ, Armstrong DG, Albert SF, et al. Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care. 2008;31(8):1679–1685.

Brownlee M, Aiello LP, Sun JK, et al. Complications of diabetes mellitus. In: Melmed S, Auchus RJ, Goldfine AB, Koenig RJ, Rosen CJ, eds. Williams Textbook of Endocrinology. 14th ed. Philadelphia, PA: Elsevier; 2020:chap 37. 

Faglia E, Clerici G, Caminiti M, Curci V, Somalvico F. Feasibility and effectiveness of internal pedal amputation of phalanx or metatarsal head in diabetic patients with forefoot osteomyelitis. J Foot Ankle Surg 2012;51:593-8.

Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care. 1998 May;21(5):855-9.