Prevention Of Foot Ulcers

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Based on the results of clinical examination, and/or laboratory testing and imaging studies, every patient with diabetes may be classified on the basis of the risk for foot problems (Table 2.5). This classification helps as a guide for patient management. Patients with active foot ulcers are not included in this classification.

Inappropriate footwear is a major cause of ulceration. The aim of providing special shoes and insoles (preventive foot wear) to diabetic patients at risk for foot ulceration, is to reduce peak plantar pressure over areas 'at risk', and to protect their feet against injuries from friction. Although there is limited scientific information about shoe selection, recommendations can be made in this regard, based on risk

Ischemic Ulcer
Figure 2.9 Neuro-ischemic ulcer on heel. This was a painless ulcer due to severe diabetic peripheral neuropathy. Another neuro-ischemic ulcer is seen under the first metatarsal head. Claw toes and lateral plantar cracks on the midfoot are also evident
Table 2.5 Classification of categories of diabetic patients based on the risk for ulceration

Risk category


Protective sensation is intact; the patient

may have foot deformity


Loss of protective sensation


Loss of protective sensation and high

plantar pressure, or callosities, or

history of foot ulcer


Loss of protective sensation and history of

ulcer, and severe foot or toe deformity

and/or limited joint mobility; significant

peripheral vascular disease

(Modified from Chantelau E. Footwear for the high-risk patient. In Boulton AJM, Connor H, Cavanagh PR (Eds), The Foot in Diabetes (3rd edn). Chichester: Wiley, 2000; 131-142, with permission).

(Modified from Chantelau E. Footwear for the high-risk patient. In Boulton AJM, Connor H, Cavanagh PR (Eds), The Foot in Diabetes (3rd edn). Chichester: Wiley, 2000; 131-142, with permission).

stratification studies. Shoes for the patient at risk for ulceration should have certain characteristics. High heel shoes are completely inappropriate, as they shift body weight towards the forefoot, and increase pressure under the metatarsal heads. Patients with toe deformities need shoes with sufficient room in the toe box to prevent

Neuro Ischemic Ulceration
Figure 2.10 Neuro-ischemic ulcer in the medial aspect of the right first metatarsal head with fibrous tissue and necrosis on its bed

friction and pressure on the dorsum of the toes.

A recent study from the UK estimated that providing preventive footwear for 700 patients at risk for foot ulceration per year (with an average total cost of €179,000), would only need to prevent two below-knee amputations per year in order to be cost-effective, since the total cost of an amputation procedure is about €88,000.

Foot deformity is defined according to the 'International Consensus on the Diabetic Foot' as 'the presence of structural abnormalities of the foot such as presence of hammer toes, claw toes, hallux valgus, prominent metatarsal heads, status after neuro-osteoarthropathy, amputations or other foot surgery'. Additional foot deformities which can also lead to foot ulceration are described in other chapters of this book.


Patients in this category are characterized by preserved protective sensation and normal blood supply to their feet. These patients should have their feet examined on an annual basis, as asymptomatic nerve or vascular damage may develop. There is no need for special footwear. Patients should be instructed to choose shoes of proper style and fit, which pose no risk to their feet should they develop loss of sensation or inadequate blood supply to the feet. Athletic footwear is a good choice.


Correct foot care should be explained to all patients classified in categories 1 -3, and these patients should be examined in the outpatient diabetes clinic every 4 months. Loss of protective sensation should be 'replaced' by increased awareness of situations which threaten the foot. Patients in category 1 are at twice the risk of developing foot ulcers than those in category 0. Particular care should be taken when these patients buy new shoes. Patients with loss of protective sensation tend to select shoes which are too small because they are more able to feel a tight shoe. Shoes should not be too loose either. The inside of the shoe should be 1-2 cm longer than the foot itself. The internal width should be equal to the width of the foot at the metatarsopha-langeal joints. The fitting must be carried out with the patient in the standing position and preferably at the end of the day.

All patients with loss of protective sensation should have soft, shock-absorbing stock insoles in all shoes they wear. Such insoles are usually made of open cell urethane foam, microcellular rubber or polyethylene foam (plastazote). According to the design of the insole and the material used, peak plantar pressure reduction during walking may range from 5 to 40%. As insoles may take up considerable space inside the shoe, care should be taken to allow sufficient room for the dorsum of the foot (by the use of extra depth stock shoes) otherwise ulceration may develop in this area. Many materials used in footwear lose their effectiveness in a relatively short time, depending on the patient's degree of activity. Therefore, regular replacement of the insoles is necessary at least three times a year. Shoes should also be changed at least once a year. Some specifically designed socks (padded socks) may be also be used, since these reduce peak plantar pressures during walking by up to 30%.


Education of patients who are at risk of developing foot ulceration is the cornerstone of disease management. Patients should fully understand the risks posed by the loss of protective sensation or an inadequate blood supply to their feet. Education of the patient at risk may reduce the incidence of foot ulcers and subsequently amputations.

The patient at risk for foot ulceration should:

• Inspect his or her feet every day, including areas between toes. Inspection of the sole may be accomplished using a mirror.

• Let someone else inspect his or her feet in cases where the patient is unable to do it.

• Avoid walking barefoot any time, in- or outdoors.

• Avoid wearing shoes without socks, even for short periods.

• Buy shoes of the correct size.

• Avoid wearing new shoes for more than 1 h per day; feet should be inspected after taking off new shoes; in the case of foot irritation the patient should inform the healthcare provider.

• Change shoes at noon, and, if possible, again in the evening; this prevents high pressures remaining on the same area of the foot for a prolonged period.

• Inspect and palpate the inside of his or her shoes before wearing them.

• Wash his or her feet every day, taking care to dry them, especially the web spaces.

• Avoid putting his or her feet onto heaters.

• Test the water temperature before bathing using his or her elbow; the temperature of the water should be less than 37 °C.

• Avoid the use of chemical agents or plasters and razors for the removal of corns and calluses; they must be treated by a health care provider.

• Cut the nails straight across.

• Wear socks with seams inside out, or preferably without any seams at all.

• Use lubricating oils or creams for dry skin, but not between toes.

• Inspect his or her feet after prolonged walking.

• Notify his or her healthcare provider at once, if a blister, cut, scratch, sore, redness or black area develops, or if any discharge appears on socks.


Patients in this category do not usually need custom-made shoes. The use of appropriate insoles, which reduce peak plantar pressures under specific areas, is usually enough; these are inserted in commercially available extra-depth shoes. Insoles must be custom-molded and shock-absorbing. The idea is to redistribute plantar pressures by the use of such insoles, that is, to decrease the load from regions 'at-risk' to 'safe' regions. In addition, insoles reduce shear stress since total contact minimizes the horizontal and vertical foot movement. These insoles have two or three layers and are made of materials of different density. A thin layer of the material with the lowest density (the most potent shock-absorbing material, usually cross-linked polyethylene foams) is placed at the foot-insole interface; the firmest material (acrylic plastics, thermoplastic polymers or cork) is placed at the shoe-insole interface. A soft, shock-absorbing, durable material (closed cell neoprene, rubber or urethane polymer) is placed between them (Figures 2.11 and 2.12). Appropriate insoles for the patient at risk for ulceration should have a minimum thickness of 6.25 mm. Patients at high risk require thicker (12.5 mm) insoles.


These patients need the greatest help to remain free of foot ulceration. Patients in this

Figure 2.11 Upper side of a three-layer custom-made insole used to offload pressure on the forefoot. The upper layer is composed of cross-linked polyethylene foam, the middle layer of polyurethane, and the lower layer of cork

category are 12-36 times more likely to develop foot ulcers than patients in category 0. Severe foot deformities and limited mobility of the foot joints are associated with high plantar pressures.

Limited joint mobility is defined as a limitation in dorsiflexion of the first metatar-sophalangeal joint of more than 50° when the patient is seated (hallux rigidus).

Patients with severe peripheral vascular disease are also included in this category. Inadequate circulation makes the thin skin vulnerable to ulceration.

In addition to custom-molded insoles, custom-made and extra depth-shoes are

often necessary. Patients with recurrent foot ulcerations, or an active lifestyle, often need modifications of the outsole. In the rocker style shoe the rigid outsole rotates over a ridge (fulcrum) as the patient walks; this ridge is located 1 cm behind the metatarsal heads (see Figure 5.2). The rocker outsole allows the shoe to 'rock' forward during propulsion before the metatarsophalangeal joints are allowed to flex, thereby reducing the pressure applied to the forefoot. In a roller style shoe the contour of the outsole is a continuous curve without the ridge used in the rocker style. During walking, as the person lifts the heel, the shoe rolls forward on the curved outsole. This prevents the pressure from remaining in one region. Rocker style shoes are more effective in reducing forefoot plantar pressure than the roller style shoes.

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  • Codi
    Where are neuroischemic ulcers often located?
    7 years ago

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