The Diabetic Foot


Complications in the diabetic foot are mostly caused by a triad of ischemia, diabetic neuropathy, and infection. [1]

Statistics about the impact of diabetic foot complications:[1]

  • Foot ulcer complications are the main reason why people with diabetes are hospitalized and have to undergo amputations.
  • 20-40% of all the health care costs comprised for diabetes are for diabetic foot complications
  • 7-10% of patients with diabetes and neuropathy will develop an ulcer; this increases up to 30% for patients with diabetes and other comorbidities.
  • 5-8% of patients will undergo a major amputation 1 year after developing a diabetic ulcer.
  • A foot ulcer preceded 85% of diabetes related amputations.
  • “Diabetes increases the risk of amputation 8-fold in patients aged >45 years,8 12-fold in patients aged>65 years and 23-fold in those aged 65––74 years.”

More information on Diabetes is available from these Physiopedia pages: DM Type 2 and DM Type 1, Diabetes

Specific Foot Conditions

Diabetic Neuropathy

Due to diabetic neuropathy patients do not have the protective sensation in their feet. Thus the patient will not feel any trauma, like stepping
Diabetic foot ulcer.jpeg
on something sharp or wearing tight shoes. This could lead to continuous tissue damage, ulceration, foot deformities, increased plantar pressure, and infection. [2]

Diabetic Neuropathy

Diabetic Foot Ulcers and Delayed Wound Healing

  • In the diabetic foot peripheral arterial disease (PAD) is seen as the primary cause for vascular impairment.[1]
    Foot ulcer.jpeg

  • The risk of developing PAD is increased with diabetes and ischemia is considered the biggest culprit delaying wound healing.[1]
  • Diabetic neuropathy and ischemia combined is called neuroischemia. In these cases the wound healing is affected by the severity of the ischemia.[1]
  • Diabetes Mellitus and Diabetic Ulcers

Diabetic Foot Infections

  • The most common sign is increased ulcer exudation rate.[1]
  • Diabetic foot infections may lead to poor glycemic control. [1]
  • There is a 50% delay in diagnosing deep foot infections in diabetes patients because the infection markers in their blood tests are found absent. [1]
  • Infections in a diabetic foot can rapidly spread to the rest of the body and if not treated properly could lead to a life-threatening general septic infection [1]

Diabetic Foot (Charcot foot/joint)

Also known as Charcot-Marie-Tooth Disease or Diabetic foot arthropathy.

They may present with:

  • muscle weakness in the feet, ankles, legs and hands
  • an awkward way of walking (gait)
  • highly arched or very flat feet
  • numbness in the feet, arms and hands
    Charcot-marie-tooth foot.jpeg

More information available from  Charcot-Marie-Tooth Disease - NHS Choices (2012).


Clinical Examination according to Lep¨antalo et al. [1]

  • History
    • General (Medications, diseases, cardiovascular risk factors, work, hobbies, lifestyle, diabetes symptoms/complications
    • Foot specific (risk factors and information about present ulcer – duration, treatment, aetiology)
  • Inspection (at least once a year)
  • Vascular
    • Dorsalid Pedis Pulse 
    • Tibialis posterior pulse
    • Venous refilling time - >5sec on dependency
    • Foot appearance
  • Neurological
    • 10-gram (5.07) Semmes––Weinstein monofilament 
    • Vibration(128 Hz-tuning fork)
      Tuning fork.jpeg
    • Pinprick discrimination and tactile sensation on the dorsum of the foot
    • Achilles tendon reflexes
    • Observe for foot deformities or bony prominences 
  • Ulcer – look for perfusion, extent and size, and infection
  • Infection
    • Local signs and symptoms of inflammation: purulent secretion, redness, warmth, swelling, pain, delayed healing, and or bad odor.
    • Systemic signs: fever, and poor general condition
    • Increased exudation in the ulcer
  • X-rays to determine the presence of foreign bodies, gas, osteomyelitis, osteolysis, or joint effusion
  • MRI, bone scan or CT scan to determine the extent of the infection
  • Non-invasive vascular studies
    Ankle-brachial index.jpeg
    • Ankle pressure
    • Ankle-brachial systolic pressure index (ABI) (<0.6indicates significant ischemia in respect to wound healing)
    • Toe pressures (<30 mmHg indicates severely impaired healing)
  • Vascular imaging
  • Sub-talar ROM (any reduction may increase plantar pressures during walking) [2]

Diabetic foot/stump assessment form


Management / Interventions

Physical Therapy

  • Physical Therapists are involved in both the prevention and management of diabetic foot complications. [4] This is done by gait, posture, and foot off-loading education and training.[4]

Medical Management

  • Antibiotic treatment is indicated in all infected wounds in combination with wound care, until the infection is cleared up.[1]
  • Hospitilisation, immobilisation, and IV antibiotics are indicated for limb threatening or uncontrolled infections.[1]
  • Urgent surgery is indicated if the infection is "accompanied by a deep abscess, extensive bone or joint involvement, crepitus,
    substantial necrosis or gangrene, or necrotising fasciitis."[1]  Lepäntaloa et al. recommend that "surgical intervention for moderate or severe infections is likely to decrease the risk of major amputation."[1]


These articles are recommended for further in depth reading on the subject:

  1. Lepäntaloa M, Apelqvistc J, Setaccie C, Riccof JB, de Donatoe G, Beckerg F, Robert-Ebadig H, Caoh P, Ecksteini HH, De Rangok P, Diehml N. Chapter V: Diabetic Foot. European Journal of Vascular and Endovascular Surgery. 2011;42(S2):S60-74
  2. Pedrosa HC, Leme LA, Novaes C, Saigg M, Sena F, Gomes EB, Coutinho A, Borges Carvalho WJ, Boulton A. The diabetic foot in South America: progress with the Brazilian Save the diabetic foot project. International Diabetes Monitor. 2004;16(4):17-23.
  3. Turan Y, Ertugrul BM, Lipsky BA, Bayraktar K. Does physical therapy and rehabilitation improve outcomes for diabetic foot ulcers?. World journal of experimental medicine. 2015 May 20;5(2):130.

Case Studies

Follow this link to read more case studies.


  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 Lepäntaloa M, Apelqvistc J, Setaccie C, Riccof JB, de Donatoe G, Beckerg F, Robert-Ebadig H, Caoh P, Ecksteini HH, De Rangok P, Diehml N. Chapter V: Diabetic Foot. European Journal of Vascular and Endovascular Surgery. 2011;42(S2):S60-74.
  2. 2.0 2.1 2.2 Zakaria HM, Adel SM, Tantawy SA. The Role of Physical Therapy Intervention in the Management of Diabetic Neuropathic Foot Ulcers. Bull. Fac. Ph. Th. Cairo Univ. 2008 Jul;13(2).
  3. Youtube Video: The Diabetic Foot Exam
  4. 4.0 4.1 Kalra S, Kalra B, Kumar N. Prevention and management of diabetes: the role of the physiotherapist. Diabetes Voice. 2007;52 (3)
  5. Dubinsky RM, Miyasaki J. Assessment: Efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review) Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2010 Jan 12;74(2):173-6.