The Diabetic Foot: Pathophysiology, Evaluation, and Treatment

The pathophysiology of the diabetic foot ulcer and soft-tissue infection is due to neuropathy, trauma, and, in many patients, concomitant peripheral artery occlusive disease. Diabetic neuropathy results in foot deformity, leading to increased skin pressure with walking. Once a foot ulcer develops, the limb is at high risk for invasive infection and, when combined with peripheral artery occlusive disease, the patient should be considered to have critical limb ischemia. A multidisciplinary approach to care for the diabetic foot is recommended, which includes annual (3-month intervals in high-risk patients) assessments by a primary care physician and referral to a podiatrist and vascular surgeon for diabetics with a foot ulcer for evaluation of foot arterial perfusion and off-loading therapy to reduce plantar skin pressure with walking. When invasive foot infection develops and tissue beneath the fascia is involved, inpatient care is recommended for systemic antibiotic therapy, vascular laboratory testing of artery limb perfusion, and surgical debridement of infected tissue. The goals of treatment are to achieve a healed foot and keep the patient ambulatory.