East Coast Podiatry
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Last Updated: 06 Jan 2021

Diabetic Foot Ulcer and Wound

Diabetic Foot Ulcer

Podiatrists are pivotal in the prevention and early diagnosis of diabetic foot complications. Management of the diabetic foot requires a thorough knowledge of the major risk factors for amputation, frequent scrupulous evaluation, and regular preventative maintenance. Patients at most risk for foot ulceration are those with diabetic neuropathy, structural foot deformity and peripheral arterial occlusive disease (PVD/PAD).

Avoiding amputation requires regular inspection of the diabetic foot by the patient and by a podiatrist. This is the easiest, least expensive and most effective measure for preventing foot complications; it can reduce a person’s amputation rate by up to 85%. Diabetic foot management requires practitioners to recognise the risk factors for limb loss, which usually span across multiple medical disciplines.

Diabetic foot ulcers typically form due to overloading of a particular area of the foot. It can also start as a small abrasion or blister where footwear is rubbing the foot. Diabetic ulcers describe wounds which do not heal normally and is at high risk of deterioration and infection, due to a multitude of interrelated diabetic complications. It is estimated that 15-25% of the adult diabetic Singaporean population experience a foot ulcer in their lifetime. 84% of all non-traumatic lower leg amputations started with a foot ulcer. Statistics show that functional decline often occurs quickly in patients with leg amputation, resulting in early death.

Blindness, foot ulceration leading onto amputation and kidney failure are the most well-known and dreaded complications of diabetes. People often worry about “leg gangrene” and pair it with diabetes; this is actually the end-stage consequence of a foot ulcer as tissue death sets in.

What can my podiatrist do for me?

Podiatrists at East Coast Podiatry Centre have a reputation for high-intensity wound treatments. Our achieved average healing time for even chronic complex wounds is less than 3 months. Your podiatrist will likely:

  • Run though a thorough examination and extensive medical history-taking.
  • Full diabetic foot examination to classify your diabetic foot status.
  • Test for neuropathy and vascular insufficiency (doppler/ ABPI/ TPBI).
  • Judicious wound debridement, cleansing and care using specialised dressings.
  • In-clinic wound treatment to promote healing through increasing localised circulation and influx of regenerative cells.
  • Casting of the lower limb depending on the need (soft, compressive, fixed, removable, fibreglass, plaster of Paris).
  • Long-term offloading, footwear modification and customised orthotics to prevent recurrence of wound.
  • Regular foot care when needed to ensure the wound site becomes as normal as possible, reducing the need for follow-up visits. Stabilise the foot condition.
  • Yearly diabetic foot examination to track foot condition and overall risks.
  • Onward to surgical referral if required.

Our podiatrists aim to keep diabetic patients ambulating and living an active lifestyle with minimized risk of wounds and infections. Everything your podiatrist does for you is to avoid amputation and a worsening foot condition. If your foot condition worsens and requires surgical intervention, your podiatrist will determine the severity and act accordingly and swiftly to ensure you receive prompt referral to the correct specialist (endocrinology, orthopaedic, or vascular).

Risk Factors for Lower Extremity Amputation

  • Peripheral neuropathy
  • Structural foot deformity (bunions, toe deformities, collapsed foot, Charcot foot)
  • Peripheral Vascular Disease (PVD) / Peripheral arterial disease (PAD)
  • Ulceration or non-healing wounds
  • Infection
  • Lack of compliance to recommended treatments
  • Uncontrolled blood sugar levels
  • Trauma to the feet and lower limbs
  • Not inspecting the feet regularly for wounds, skin changes and infection
  • Cigarrette smoking

Patient education regarding foot hygiene, nail care and proper footwear is crucial to reducing the risk of an injury that can lead to ulcer formation. Adherence to a systematic regimen of diagnosis and classification can improve communication between podiatrist and diabetes specialists, and facilitate appropriate treatment of complications. This team approach can ultimately lead to a reduction in lower extremity amputations related to diabetes.

Why do diabetic wounds not heal?

Poor sensation causes diabetics to neglect foot injuries, including wounds and fractures. Poor blood flow impairs healing and heightens the risk of infection. The lack of pain causes the patient to treat a wound as less serious than it actually is, even while he/she is undergoing weekly wound treatment. All of these factors can allow a foot ulcer to quickly worsen to gangrene.

Assuming all other factors being equal (general health, good glycemic control, smoking cessation, etc), the decisive clincher to complete healing is absolute adherence to the international gold standard of diabetic foot ulcer treatment, on the part of both the doctors and the patients.

While the gold standard is well-known to the medical profession, strict adherence in actual practice is very difficult. Coordinated care amongst different medical specialities is paramount, specialist skill is required in each case, public health strategies and social burden of care are real-world considerations, not to mention poor compliance on the part of many patients due to lack of awareness. All of this often results in only partial compliance to the gold standard of treatment, which dramatically reduces outcome success.

In order to tackle the above problem, a multi-pronged approach is necessary not only at the medical practitioner level but also at the community and even the national level. Singapore has one of the highest incidences of diabetes among developed countries, second only to the United States. The percentage of adult diabetes has risen to 11% of all Singaporeans and is projected to increase. Health Minister Gan Kim Yong declared Singapore’s “War on Diabetes” in 2016 to address these alarming trends and raise the generally poor awareness of diabetes amongst Singaporeans.

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