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Diabetic foot ulcers are a serious complication of diabetes – here’s why.

Man putting on socks.

Warning: graphic images

Diabetes is one of the most common diseases in the world. In 2015, the estimated prevalence of diabetes was 3.4 million or 9.3% of the population, and is predicted to rise to 5 million or 12.1% of the population by 2025, representing a 44% increase from 2015 to 2025.1

Long-term complications are gradual, with a higher possibility of development in people living with diabetes for several years. With 15%-25% of patients with diabetes at risk, diabetic foot ulcers (DFU) are one of the most severe complications. Additionally, as the DFU worsens, the risk of amputation increases – nearly 84% of patients who undergo lower limb amputation had a DFU present prior to the amputation.

DFUs are typically classified by the depth of the wound and the presence of infection. Several classification systems for diabetic foot ulcerations have been created, including the most widely used Wagner Classification System.

This system classifies DFU based on various factors, such as penetration depth. It assigns a grade based on the severity – grade 1 being the lowest (superficial diabetic ulcer) and grade 5 the highest (gangrene of the whole foot).2

 How DFU develops: a range of risk factors.

There are a variety of causes for the development of diabetic foot ulceration. Some of the most common ones are peripheral neuropathy, peripheral arterial disease, foot deformity, poorly controlled diabetes, and smoking.

Peripheral neuropathy can manifest itself as one of three types – sensory neuropathy, motor neuropathy and autonomic neuropathy. In the first type, the patient is unaware of skin breakdown due to sensory loss. In the second, intrinsic muscles in the foot can be affected, causing deformity and muscle imbalance and could lead to DFU. In autonomic neuropathy, dry and cracked skin and decreased sweating could make the patient vulnerable to skin breakdown and possible infection.3

Peripheral arterial disease (PAD) damages the lower limb arteries. In the presence of PAD in a DFU, lower limb amputation becomes a possibility, especially when significant tissue loss and infection have occurred.4,5 Signs and symptoms include pain when walking or resting, tight and shiny skin, thickened and brittle toenails, lack of hair growth on the foot or leg.

diabetic foot

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Additionally, structural deformities in the foot could lead to abnormal mechanical pressures and skin breakdown. Common deformities include hammertoe deformities, claw toe deformities, prominent metatarsal heads, plantar fat pad atrophy, pes cavus (high arch), Charcot foot deformity, and equinus (limited upward bending motion of the ankle joint) are some common deformities seen in the diabetic foot.6,7,8

When blood glucose levels are high white blood cells are affected. If a patient’s white blood cells don’t function properly and their diabetes is not under control, they become more prone to infection, and their body is unable to heal wounds. This can lead to further complications like cellulitis and osteomyelitis.9,10

A DFU shouldn’t remain open for long.

There is a possibility of developing osteomyelitis if the diabetic foot ulcer remains open, and the risk becomes higher the longer it’s left untreated. Osteomyelitis is a devastating complication and can lead to bone debridement, or worse, amputation.

Tests like plain film x-rays, CT scan, nuclear medicine, MRI scan, and inflammatory markers, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) can aid in the diagnosis of osteomyelitis. For patients with a DFU, start with a baseline x-ray. If conventional wound care fails or the wound extends to deeper structures, including a positive probe to bone, use advanced imaging. 

diabetic ulcer

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diabetic ulcer

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Managing DFUs in the real world.

In the management of DFUs, the main objective is to prevent amputation by closing the wound as quickly as possible. Debridement, offloading (an essential component in DFU management), treating any underlying infection and/or inflammation, managing wound exudate, and promoting wound edges should all be included in wound care.11,12

The gold standard for patients is total contact casting. When that’s not an option, controlled ankle motion (CAM) walkers should be considered, as well as the use of wheelchairs, walkers, and modified shoes.13

Medical solutions that could aid in wound healing.

Negative Pressure Wound Therapy (NPWT) is another way you can help create an environment that promotes the wound healing process. The application of negative pressure to a wound also assists with the removal of wound fluids, which can include infectious materials. Wound healing can be aided using negative pressure wound therapy (NPWT), which manages excess wound exudate. Depending on the size of the wound, some NPWT options include the 3M™ ActiV.A.C.™ Therapy System or the disposable 3M™ Snap™ Therapy System. 

The 3M™ ActiV.A.C.™ Therapy System is a portable NPWT system designed for ambulatory patients. The therapy unit is intended to help patients resume their activities of daily living, while still receiving the proven wound healing benefits of 3M™ V.A.C.™ Therapy.

The 3M™ Snap™ Therapy System is small and discrete, as it can be hidden under clothes. It helps the patient preserve their quality of life as there’s minimal interference with everyday life, even when they are in a social setting or sleeping. 

SNAP Lower Extremity

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Promogran PRISMA

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There’s no question that diabetic foot wounds are a serious complication that could lead to amputation. It’s critically important to identify its causes early in order to treat wounds particularly ulcers effectively. Medical solutions like the 3M™ Promogran Prisma™ Wound Balancing Matrix, 3M™ ActiV.A.C.™ Therapy System, or 3M™ Snap™ Therapy can be used to aid wound healing. To learn more about 3M solutions, use the Active and Advanced Wound Care & Skin Integrity Solutions chart or contact a representative, below.


Disclaimer: This information is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of a doctor with any questions regarding this medical condition. Do not disregard professional advice or delay in seeking it because of something you read here.


1: Diabetes Canada. Diabetes statistics in Canada. 2017. Available from:

2: Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJ. A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems. Diabetes Care. 2001;24(1):84-88

3: Sumpio BE. Contemporary evaluation and management of the diabetic foot. Scientifica (Cairo). 2012;2012:435487.

4: Won SH, Chung CY, Park MS, Lee T, Sung KH, Lee SY, et al. Risk factors associated with amputation-free survival in patient with diabetic foot ulcers. Yonsei Med J. 2014;55(5):1373–1378

5: Akbari CM, LoGerfo FW. Microvascular changes in the diabetic foot. In: Veves A, Giurini JM, LoGerfo FW, eds. The Diabetic Foot. 1st ed. Totowa, NJ: Humana Press; 2002:99-112

6: Bus SA, Maas M, Michels RP, Levi M. Role of intrinsic muscle atrophy in the etiology of claw toe deformity in diabetic neuropathy may not be as straightforward as widely believed. Diabetes Care. 2009;32(6):1063-1067.

7: van Schie CH, Vermigli C, Carrington AL, Boulton A. Muscle weakness and foot deformities in diabetes: relationship to neuropathy and foot ulceration in caucasian diabetic men. Diabetes Care. 2004;27(7):1668-1673.

8: Heitzman J. Foot care for patients with diabetes. Top Geriatr Rehabil. 2010;26(3):250-263.

9: Wild T, Rahbarnia A, Kellner M, Sobotka L, Eberlein T. Basics in nutrition and wound healing. Nutrition. 2010;26 (9):862-866.

10: Sharp A, Clark J. Diabetes and its effects on wound healing. Nurs Stand. 2011;25(45):41-47.

11: Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen. 2003;11 Suppl 1:S1-28.

12: Chadwick P, Edmonds M, McCardle J, Armstrong D. Best Practice Guidelines: Wound management in diabetic foot ulcers. Wounds Int. 2013:1-23

13: Snyder RJ, Hanft JR. Diabetic foot ulcers - effects on quality of life, costs, and mortality and the role of standard wound care and advanced-care therapies in healing: a review. Ostomy Wound Manage. 2009;55(11):28- 38.

About the Author

[enBio=Dr. Robert Klein completed podiatric medical school in Chicago at the Rosalind Franklin University of Medicine and Science, Scholl College of Podiatric Medicine. Dr. Klein continued his surgical training as the Chief Resident at Michigan Health Center in Detroit. He is a Clinical Assistant Professor in the Department of Surgery at the University of South Carolina School of Medicine (USCSOM) Greenville and specializes in wound care, limb preservation, and Dr. Klein is a consultant for 3M.],[enJob=DPM, FACFAS, CWS],[frBio=Le Dr Robert Klein a terminé ses études de médecine podiatrique à Scholl College of Podiatric Medicine de l’Université Rosalind Franklin of Medecine and Science, à Chicago. Le Dr Klein a poursuivi sa formation chirurgicale en tant que résident en chef au Michigan Health Center à Detroit. Il est professeur adjoint clinique au Département de chirurgie de l’École de médecine de l’Université de Caroline du Sud (USCSOM) à Greenville et se spécialise dans les soins des plaies, la préservation des membres, et le Dr Klein est consultant pour 3M.],[frJob=DPM, FACFAS, CWS]

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