Which Patients Are At Risk For Foot Ulceration

Risk factors for foot ulceration are as follows.

• History of previous foot ulceration or amputation

• Peripheral neuropathy

• Peripheral vascular disease

• Trauma (poor footwear, walking barefoot, objects inside the shoes)

• Foot deformities (prominent metatarsal heads, claw tow, hammer toe, pes cavus, nail deformities, deformities related to previous trauma and surgery, bony prominences, etc.)

• Callus formation

• Neuro-osteoarthropathy

• Limited joint mobility

• Long duration of diabetes

• Poor diabetes control

In addition to these well-recognized risk factors for foot ulceration, several—but not all — studies have shown that foot ulcers are more common in male patients. In addition, social factors including low social status, poor access to healthcare services, poor education and a solitary lifestyle have all been associated with foot ulceration. Another important factor for foot ulceration is poor compliance by the patient with medical instructions and neglecting to follow procedures. Edema may impair blood supply to the foot, particularly in patients with peripheral vascular disease. Inhibition of sweating (anhidro-sis) — due to peripheral neuropathy—may cause dry skin and fissures. Dry skin together with limited joint mobility and high plantar pressures contribute to callus formation.

Peripheral neuropathy and vascular disease alone do not cause foot ulceration. It is the combination of the factors mentioned above, that act together in the vast majority of cases. Trauma from either the patient's shoes or from external causes, and loss of protective sensation and peripheral vascular disease are among the major contributors to foot ulceration. Diabetic neuropathy is the common denominator in almost 90% of diabetic foot ulcers. Trauma initially causes minor injuries, which are not perceived by the patient with loss of protective sensation. As the patient continues his activities, a small injury enlarges and may be complicated by infection. The pathway to foot ulceration in diabetes is depicted in Figure 1.1.

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