Diabetic Foot

Diabetic foot is a serious health problem characterized by nerve damage (neuropathy), vascular disorders, and infections that develop in the foot area as one of the long-term complications of diabetes. Occurring in approximately 15-25% of diabetic patients during their lifetime, this condition can lead to wounds, infections, bone involvement, and even limb loss if not treated in a timely and proper manner. It is largely preventable through a multidisciplinary approach and regular follow-up.

What Is Diabetic Foot?

Diabetic foot develops as a result of the interaction of three main problems caused by uncontrolled or long-term diabetes:

Diabetic Neuropathy (Nerve Damage)

High blood sugar damages the nerves in the feet. As a result:

  • Pain, temperature, and touch sensation decrease
  • Injuries go unnoticed
  • Muscle weakness and foot deformities develop
  • Skin sweating function is impaired (dryness and cracks)

Peripheral Arterial Disease (Vascular Disorder)

Diabetes causes narrowing or blockage in the vessels going to the legs and feet:

  • Tissue oxygenation decreases
  • Wound healing is delayed
  • Infection risk increases
  • Gangrene may develop in severe cases

Susceptibility to Infection

High blood sugar weakens the immune system. Even small wounds can become quickly infected and lead to serious consequences.

Symptoms of Diabetic Foot

Recognizing the early signs of diabetic foot is of great importance:

Early Symptoms

  • Tingling, burning, or pricking sensation in the feet
  • Numbness or reduced sensation
  • Dry skin and cracks
  • Thickening or color change in nails
  • Changes in foot shape
  • Pain in legs while walking (claudication)
  • Cold feet (especially unilateral)

Advanced Stage Symptoms

  • Open wound or ulcer
  • Redness, swelling around the wound
  • Discharge or foul odor
  • Purple or black skin discoloration
  • Deformity in toes
  • Fever and signs of systemic infection
  • Tissue death (gangrene) in foot or toes

Types of Diabetic Foot

There are three main types based on the underlying mechanism:

Neuropathic Foot

  • Nerve damage dominant
  • Foot is warm, pulses are palpable
  • Sensation loss is significant
  • Wounds are usually on pressure points (sole, toe tips)

Ischemic Foot

  • Vascular disorder dominant
  • Foot is cold, pulses are weak or imperceptible
  • Sensation usually preserved
  • Wounds are at toe tips or back of heel

Neuroischemic Foot

  • Both nerve and vascular damage together
  • Most common type
  • Most complex type to treat
  • High risk of infection

Diabetic Foot Wound Classification

Wound classification is used in treatment planning.

Wagner Classification

  • Grade 0: No open wound, risk factors present
  • Grade 1: Superficial ulcer
  • Grade 2: Deep ulcer not reaching tendon or bone
  • Grade 3: Deep ulcer with abscess, osteomyelitis (bone infection)
  • Grade 4: Limited gangrene (toe or heel)
  • Grade 5: Gangrene involving the entire foot

University of Texas Classification

In addition to wound depth, the presence of infection and ischemia is also evaluated.

Risk Factors

Factors that increase the risk of developing diabetic foot:

  • Long-term and uncontrolled diabetes
  • Poor glycemic control (high HbA1c)
  • Previous foot ulcer or amputation
  • Peripheral neuropathy
  • Peripheral arterial disease
  • Visual impairment (retinopathy)
  • Chronic kidney disease (diabetic nephropathy)
  • Smoking
  • High blood pressure and cholesterol
  • Foot deformities
  • Inappropriate footwear use
  • Advanced age
  • Inadequate foot care
  • Heart diseases

Diagnostic Methods

Clinical Examination

The foundation of diabetic foot evaluation:

  • Visual assessment of the foot
  • Checking skin condition and temperature
  • Pulse examination (dorsalis pedis, tibialis posterior)
  • Reflex examination
  • Sensation examination (10 g monofilament test, vibration sensation)
  • Evaluation of foot deformities
  • Checking footwear suitability

Neuropathy Tests

  • 10 g monofilament test: Touch sensation evaluation
  • 128 Hz vibration sensation test: With tuning fork
  • Pinprick test: Pain sensation evaluation
  • Electromyography (EMG): Nerve conduction velocity measurement

Vascular Assessment

  • Ankle-brachial index (ABI): Blood pressure ratio
  • Toe-brachial index (TBI): Toe pressure
  • Doppler ultrasonography: Blood flow assessment
  • CT/MR angiography: Detailed vascular imaging
  • Conventional angiography: In cases where surgery is planned

Wound Evaluation

  • Wound culture: Identification of causative microorganism
  • Bone biopsy: When osteomyelitis is suspected
  • X-ray, MRI: For bone involvement
  • Blood tests: CRP, sedimentation, blood count, HbA1c

Diabetic Foot Treatment

Treatment requires a multidisciplinary team approach. Endocrinologists, orthopedists, plastic surgeons, vascular surgeons, infectious disease specialists, and diabetic foot nurses must work together.

Glycemic Control

The foundation of treatment. Strict control of blood sugar:

  • Supports wound healing
  • Reduces infection risk
  • Prevents progression of complications

The HbA1c target is generally below 7%, but individual targets are determined.

Wound Care

Special techniques are used in the care of diabetic foot wounds:

Debridement (Removal of Dead Tissue)
  • Surgical debridement (most common)
  • Autolytic debridement
  • Enzymatic debridement
  • Mechanical debridement

Regular debridement accelerates wound healing.

Wound Dressings
  • Selected based on the moist wound healing principle
  • Hydrocolloid, alginate, foam, silver-coated dressings
  • Changed according to the amount of discharge and wound characteristics
  • Dressing change frequency is individualized
Infection Management
  • Appropriate antibiotic therapy (based on culture results)
  • Rapid intervention in acute infection
  • Surgical debridement may be required
  • Abscess drainage is performed

Pressure Offloading

Removing the pressure load that creates the wound is key to healing:

  • Total contact cast (TCC): Gold standard
  • Removable walking boots
  • Diabetic shoes and insoles
  • Wheelchair or bed rest
  • Walking aids

Vascular Treatment

In cases accompanied by peripheral arterial disease:

Angioplasty and Stent
  • Widening of the vessel narrowing with a balloon
  • Stent placement
  • Minimally invasive method
  • Fast recovery
Vascular Bypass Surgery
  • Bypassing the blocked vessel
  • With vessel from another part of the body or artificial vessel
  • In complex cases
Medication
  • Aspirin
  • Clopidogrel
  • Statins
  • Smoking cessation

Advanced Wound Treatments

In wounds unresponsive to standard care:

  • Negative pressure wound therapy (VAC): Accelerates wound healing
  • Hyperbaric oxygen therapy: Increases oxygenation
  • Growth factors: Topical application
  • Artificial skin and tissue equivalents
  • Stem cell therapies (in research phase)

Surgical Treatment

Surgical intervention is required in some cases:

  • Wound debridement
  • Abscess drainage
  • Bone resection (in osteomyelitis)
  • Tendon repairs
  • Reconstructive surgery (flap, graft)
  • Amputation (as a last resort)

Diabetic Foot Amputation

Despite modern treatment approaches, amputation may be unavoidable in some cases:

Amputation Indications

  • Widespread tissue necrosis (gangrene)
  • Uncontrolled infection
  • Severe ischemia and revascularization is not possible
  • Life-threatening systemic infection
  • Chronic pain unresponsive to treatment

Amputation Levels

  • Toe amputation: In limited involvement
  • Transmetatarsal amputation: At the level of toes
  • Ankle (Syme) amputation
  • Below-knee amputation (BKA): Most common
  • Above-knee amputation (AKA): In widespread disease

The risk of amputation can be greatly reduced with early diagnosis and appropriate treatment.

Prevention of Diabetic Foot

Most diabetic foot wounds are preventable. Prevention strategies:

Daily Foot Care

  • Daily visual examination of feet (with a mirror)
  • Washing with warm (not hot!) water
  • Drying between toes
  • Application of moisturizer (except between toes)
  • Cutting nails straight
  • Checking for wounds, cracks, blisters

Right Shoe Selection

  • Wide, comfortable, with full toe space
  • Soft and breathable material
  • Seamless interior
  • Special shoes for diabetic feet
  • Slow break-in of new shoes
  • Should not walk barefoot

Regular Check-ups

  • At least one foot examination per year (more frequently in high risk)
  • Regular endocrinology follow-up
  • Consultations with podologist or diabetic foot nurse

Lifestyle

  • Smoking cessation
  • Regular exercise (with appropriate shoes)
  • Healthy weight control
  • Stress management
  • Limiting alcohol consumption

Diabetes Management

  • Regular use of medications
  • Regular blood sugar measurement
  • Achieving HbA1c targets
  • Compliance with nutritional recommendations

Education

  • Patient and family education is of great importance
  • How to act in case of injury should be taught
  • Early symptoms should be recognized
  • Emergency referral criteria should be known

FAQ

Healing time depends on the depth of the wound, infection status, vascular condition, and glycemic control. Superficial wounds may take 4-8 weeks, while deep and infected wounds may take several months. Some wounds may not heal for weeks or months.

Good glycemic control, regular foot examination, and appropriate footwear are the most critical factors. Regular check-ups make it possible to detect small problems before they turn into ulcers.

No. Diabetic patients should not walk barefoot, even at home. Injuries may not be noticed due to sensation loss. Comfortable and appropriate slippers or shoes should always be worn.

Low-risk patients can cut their nails carefully and straight. However, in patients with vision problems, sensation loss, or nail deformity, cutting by a podologist or diabetic foot nurse is recommended.

Each patient's individual target is different. HbA1c below 7% is generally recommended, but around 8% may be acceptable in elderly patients with comorbidities. Individualized targets are important against the risk of hypoglycemia.