Diabetic Foot Ulcer

Wagner Classification of Diabetic Foot Ulcers

Diabetic Foot Ulcers

Diabetic ulcers are a common complication of diabetes. Diabetic foot ulcers account for more than 20% of total hospital days for patients with diabetes and are the leading cause of hospital admissions among patients with diabetes.

Ulcers most commonly affect the area under your big toes and the balls of your feet. These ulcers typically form over areas where the skin is thickened and callused due to diabetic neuropathy.  These calluses cause increased rigidity in the blood vessels that may lead them to break and bleed beneath it. This eventually leads to necrosis or death of tissue from lack of oxygenation.


What does a diabetic foot ulcer look like?

The symptoms of a foot ulcer are not subtle. Usually, the first sign is drainage from your foot that might stain socks or leak out in shoes. Other symptoms include: Unusual swelling, irritation, redness, and even odors can be very alarming early signs too.

The most visible sign of a serious foot ulcer is the black tissue (called eschar) that surrounds it. This forms because there’s not enough blood flow to the area around the ulcer, and without this healthy supply, wounds turn necrotic and die off quickly.

The odorous discharge that is emitted from an ulcer can be due to gangrene. Gangrene occurs when tissue dies because of infections and pain, numbness are also symptoms in this case.

The signs of foot ulceration may not be immediately recognizable, with sometimes no symptoms until they’ve become infected.

Diabetic Neuropathy increases risk for diabetic foot ulcers

Diabetic Foot Neuropathy isn’t just a nuisance, it can be downright dangerous. Peripheral sensory neuropathy is the major independent risk factor for diabetic foot ulcerations

Frykberg, Robert G., et al. “Neurologic Procedures.” Diabetic Foot Disorders, Dec. 1999, pp. S17

For those with diabetes, the risks of wounds and ulcerations are high. Why? Because neuropathy affects 40 to 60% of diabetic patients! To make matters worse, peripheral neuropathy is a major contributing cause for lower-extremity amputation in these diabetics–with 20% developing it after 10 years and 50% who develop it eventually (after around 20 years). Thankfully though, this number may decrease as more people strive for tighter control on their blood sugar glucose levels that also contribute towards minimizing risk factors like diabetes mellitus type 1 or 2.

Why do diabetics get foot ulcers?

Diabetics often have risky foot conditions. 15% of those with diabetes will develop a lower extremity ulcer during the course of their disease, but this number can be reduced if all risk factors are monitored and addressed early on in the patient’s treatment plan.  The cumulative effects of neuropathy, deformities, high plantar pressure, glucose control duration from diagnosis to now, gender-based predispositions, poor circulation– are all contributory factors that lead to diabetic foot ulceration

What is the best treatment for diabetic foot ulcers?

Before treatment can begin, the ulcer needs to be staged.

From the Doctor: The presumed cause needs to be determined. The evaluation should include size, depth of the ulcer, as well as description of the margins, base, and geographic location of the extremity or foot. The description should note to which level the ulcer probes. It should comment on the margins and extension and if there are any sinus tracts.

Frykberg, Robert G., et al. “Ulcer Evaluation.” Diabetic Foot Disorders, Dec. 1999, pp. S18

How do you diagnose diabetic neuropathy?

If you placed your hand on a burner, you would move it abruptly due to the pain. However, with neuropathy, painful stimuli are not recognized.

Another testing for assessment of diabetic neuropathy includes vibration with a tuning fork 128 cycles at the level of the ankle and first metatarsal. Vibration perception threshold assessment with Biosthesiometer is also helpful in predicting those patients at high risk for ulceration.

Frykberg, Robert G., et al. “Neurologic Procedures.” Diabetic Foot Disorders, Dec. 1999, pp. S17 (B, S17).

The existence of odor and exudative drainage should be noted. Culture may be necessary when signs of inflammation are present. Current recommendations for culture and sensitivity include thorough surgical preparation of the wound site with curettage of the wound base for specimen or with aspiration of abscess material

Frykberg, Robert G., et al. “Ulcer Evaluation.” Diabetic Foot Disorders, Dec. 1999, pp. S18

Diabetic Foot Ulcer stages

Although no single system has been universally adopted, the classification system most often used by podiatrists was described and popularized by Wagner.

  • Grade 0 Skin intact, lead to “foot at risk” Shoe modifications with serial exams
  • Grade 1 Superficial ulcer extending through the epidermis of the skin to the dermal tissue layer. Office debridement
  • Grade 2 Deeper, full-thickness extension Operative formal debridement and contact casting
  • Grade 3 Deep abscess formation or osteomyelitis Operative formal debridement and contact casting
  • Grade 4 Partial Gangrene of forefoot Local vs. larger amputation
  • Grade 5 Extensive Gangrene Amputation

Can Foot Ulcers be cured?

Not all hope is lost! Foot ulcers can absolutely be cured or at least managed with early aggressive treatment by a trained podiatrist or foot specialist by using wound management and treatment .

Principles of Wound Management:

  • ensure adequate blood flow via clinical examination and vascular studies to prevent or control infection
  • protect and offload pressure areas with durable medical equipment such as diabetic shoes and insoles
  • custom orthotics or Ankle-foot orthotic bracing
  • accommodative padding, ensure adequate nutrition
  •  optimize the wound environment for healing with adequate and debridement to remove compromised tissue and promote healthy tissue

Management and treatment of ulcers

  • pressure relief
  • Debridement
  • wound cleansing
  • application of dressings


Seemingly superficial wounds are often like the cap of a volcano, masking seething layers of infected, necrotic tissue below. Without aggressive debridement, the true extent of the wound is obscured, the character of the infection is unappreciated, and the wound simply won’t heal. Superficialhealing (granulation) may occur, but as soon as pressure is reapplied (as in ambulation) it breaks down.

Sharp surgical debridement is often the treatment of choice using a scalpel or the shop instrumentation to remove areas of thick adherent eschar or necrotic tissue with extensive ulcers. This is the best form of debridement and can be employed in the office or operating room for more extensive cases. With deep wounds penetrating to the level of bone to bone biopsy should be performed for bacterial and fungal cultures to rule out a bone infection. The objective of surgical debridement is to remove all necrotic or infected tissue from the wound and convert a chronic wound into the acute wound to facilitate wound healing.

Advanced stage wounds that are devitalized in infected tissue require aggressive sharp surgical debridement. Debridement is the only procedure which effectively removed the thickened epithelium from around the chronic wound.

Wounds or ulcers not responding to aggressive treatment or that occur in atypical areas should be biopsied to rule out possible malignancy.

Adjunct Treatments

Adjunct treatments for diabetic foot ulcers are often necessary to help the healing process. Topical wound healing agents, enzymatic debriding agents, and wound care products with dressings such as hydrogels can be used in addition to advanced technologies like tissue replacement grafts or stem cell-grafting procedures. Working alongside a multidisciplinary team that may include an internal medicine specialist is key when treating these wounds because of their complex nature; without this treatment plan there could be risk of recurrence which would lead back to more invasive surgery on the feet in order for them heal correctly

When it comes to diabetic foot ulcers, there are many treatments that can be used. The treatment you may choose will depend on the severity of your wound and what’s best for your specific needs. If a person has an open sore or abscess in their skin due from diabetes then one thing they might do is use vacuum-assisted wounds closure with adjunctive hyperbaric oxygen therapy (HBOT) which will augment healing process by providing pressure off the wound while at same time increasing tissue oxygenation levels via daily HBOT sessions in a specially designed chamber.

The use of adjunctive therapies like Anodyne or Revitamed infrared light also help hasten recovery time and prevent recurrence.

The multidisciplinary treatment team can include: Internal medicine, endocrinologist, podiatrist, visiting nurse, vascular surgery, pedorthist (custom shoe specialist),prosthetists, nutritiondietitian, compression specialist, physical therapist, rehabilitation medicine, neurologist, plastic surgeon, orthopedic surgeon, social worker and pharmacologist.

How long does a diabetic foot ulcer take to heal?

Healing time for wounds varies based on many factors, such as wound size and location. There are also other considerations that can affect how quickly the body heals from a wound: swelling, circulation of blood or sugar levels in your system, what care you’re using to heal it with (such as pressure), etc. Healing may happen within weeks or take up to several months depending on these variables.

Getting timely treatment from a podiatrist can help you have better outcomes and faster recovery timelines.

If you are diabetic combating and you or a family member spots a sore, callous, or corn that will not heal, do not delay treatment! Make an appointment with a trained and certified diabetic foot specialist. Dr. Christopher Formanek, DPM is trained in all state-of-the-art treatments for all diabetic foot problems and is ready to assist you in recovery.  Call us today at (225) 756-0034  or fill out an online form


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