Condition
Diabetic foot ulcer treatment: healing the wound and saving the foot
Open sores on the feet of people with diabetes, and the step-by-step care, including surgery when it’s needed, that aims to heal them and keep them closed.
Medically reviewed by Dr. Efe Ozturk · Last reviewed
Watch: Diabetic foot ulcers: offloading, wound care and surgery
Read the transcript
Diabetic foot ulcer treatment works on several fronts at once. Here’s how these ulcers form, how they heal, and when surgery saves the foot. When diabetes damages the nerves of the feet, you can lose feeling, and a rubbing blister may go unnoticed. Repeated pressure in one place thickens the skin into a callus, and in a numb foot, a callus can break down into an ulcer. Common spots are under the forefoot or midfoot, and on the tips of bent toes. About half of people with a diabetic foot ulcer also have peripheral artery disease, or PAD. When too little blood reaches the foot, a wound may heal slowly, or not at all. Noninvasive circulation testing is done at our practice. Numbness can hide pain, so look at your feet every day. Call us for a blister, scrape or bruise that looks no better a few days later. Also watch for redness, warmth or soreness, a possible sign of infection. And dried blood inside a callus is often an early clue that the skin has broken down. Dr. Ozturk, a Foot and Ankle Surgeon board certified in wound care, works on four things at once. First, take the pressure off, arguably the most important step. Second, clean up the wound: usually every week or two, we trim away callus and dead tissue. Third, treat infection: about 50% to 60% of these ulcers become infected. Fourth, restore blood flow: if it’s reduced, we refer you to a vascular specialist. For an ulcer under the forefoot or midfoot, with no serious infection or poor circulation, a knee-high device you can’t remove comes first. These devices likely heal more ulcers than removable ones. We fit these devices ourselves, show you how to get around safely, and check your skin at each visit. Some ulcers don’t heal with good non-surgical care, because dressings and devices can’t reach the cause. It may be infected bone, or a bony bump or tight tendon loading the same spot with every step. If offloading hasn’t healed an ulcer under the forefoot, the guideline advises considering surgery, such as an Achilles tendon lengthening. Dr. Ozturk performs these operations, drains infection and removes infected bone, for the ulcers that need them. In a randomized trial of 64 people with a forefoot ulcer and a tight calf, most ulcers healed in a cast either way. All 30 healed with an Achilles tendon lengthening, and 88% without it. But by about two years, 38% had come back after the lengthening, versus 81% without it. Surgery works alongside offloading, infection control and blood flow. Surgery to take pressure off an ulcer isn’t done while blood flow is severely reduced. In one study, infection after foot and ankle surgery followed 9.5% of operations in people with diabetes, and 2.4% without. Tendon procedures can also shift pressure elsewhere; we go over these trade-offs with you before any operation. After an ulcer heals, an estimated 42% of people develop another within a year, and 65% within five years. The guideline recommends footwear shown to relieve pressure, and we provide therapeutic shoes and custom inserts. We also schedule check-ups by your level of risk, and treat any callus or warm spot early. About 80% of leg and foot amputations in people with diabetes follow a foot ulcer, so we’d rather see a wound early. See us within a day or two for any foot wound that isn’t healing, especially if you have diabetes. For spreading redness with fever, a cold, pale or blue foot, or black tissue, call 911 or go to an emergency department. Dr. Ozturk sees patients in Lyndhurst, Paramus and Millburn. To learn more, visit our website, or call the office to arrange a visit.
General education only; not a substitute for individual medical advice.
Why a diabetic foot ulcer forms
When diabetes damages the nerves of the feet (peripheral neuropathy (external site)), you can lose feeling there. A stone in your shoe or a rubbing blister may then go unnoticed, and the small wounds they leave can become infected.[2]
Repeated friction or pressure in one place thickens the skin into a callus, and in a numb foot a callus can break down into an ulcer.[2] Common spots are under the forefoot or midfoot and on the tip or underside of a bent toe.[1] A tight calf that limits ankle motion has been linked to ulcers under the ball of the foot.[5] Charcot foot can also reshape the foot into a “rocker bottom.”[2]
Swipe sideways to see the whole drawing.
Peripheral artery disease (PAD), present in about half of people with a diabetic foot ulcer, raises the risk of serious problems in the leg, heart and blood vessels.[3] When too little blood reaches the foot, a wound or an infection may heal slowly, or not at all.[2]
Signs to watch for
Numbness can hide pain, so trust your eyes. Look at your feet every day, and call us promptly if you see:
- a blister, scrape or bruise that looks no better a few days later
- redness, warmth or soreness in the skin, a possible sign of infection
- dried blood showing inside a callus, often an early clue that the skin underneath has broken down[2]
If an infected area turns black or starts to smell bad, it may be gangrene,[2] which needs emergency care, as described under when to seek care. See also a red, hot, swollen foot and dark or black toes.
How the ulcer is evaluated
The International Working Group on the Diabetic Foot (IWGDF) recommends describing ulcers with SINBAD (Site, Ischemia, Bacterial infection, Area and Depth).[6] It also recommends grading infection with the IDSA/IWGDF system, and considering WIfI (Wound, Ischemia and foot Infection) when PAD is present.[6]
No score can yet predict how one person’s ulcer will turn out,[6] so we measure your wound at every visit and judge the plan by its progress. X-ray, ultrasound and noninvasive circulation testing are done at our practice; CT or MRI is arranged at an outside imaging center. See how a foot wound is evaluated.
The healing plan: four things at once
Dr. Efe Ozturk, a Foot and Ankle Surgeon, is board certified in wound care (FAPWH) and in podiatric medicine (DABPM). Wound care is available at all three of our offices.
1. Take the pressure off. For an ulcer on the sole under the forefoot or midfoot of a numb foot, a knee-high device you can’t remove comes first.[1] If that isn’t suitable, a removable knee-high or ankle-high device is the second choice.[1] If the ulcer is also infected or blood flow is reduced, a non-removable device may still suit a mild problem; otherwise the guideline favors a removable one.[1] A serious infection or badly reduced blood flow is treated first.[1] Non-removable devices may cause new skin problems, so we check your skin at each visit.[4] We apply total contact casts and other non-removable devices ourselves and show you how to get around safely.
2. Clean up the wound. Removing dead tissue (debridement) and preparing a healthy wound bed are central to healing a chronic ulcer.[7] Visits are usually every week or two while the wound heals. At each one we trim away callus and dead tissue (wound debridement), measure the wound and adjust the dressings.
3. Treat infection. About 50% to 60% of diabetic foot ulcers become infected.[8] The IWGDF/IDSA infection guideline sets out how to grade severity, collect samples that identify the germs, choose antibiotics and decide when surgery is needed.[9] When a wound shows signs of a diabetic foot infection, we start antibiotics and tailor them to the culture results.
4. Restore blood flow. Vascular guidelines describe who with PAD and a foot ulcer should be prioritized for revascularization, and how to choose the procedure.[3] If your circulation is reduced, we refer you to a vascular specialist for advanced imaging and any procedure to restore blood flow.
If good standard care hasn’t healed a wound, the IWGDF gives conditional support to a few add-ons: placental-derived products, negative-pressure therapy for wounds after surgery, and hyperbaric oxygen for ulcers with reduced blood flow.[7] The evidence behind them is still weak.[7] For the wounds that need more, we offer placental-tissue and other skin substitutes, negative-pressure therapy after surgery, and skin grafts and flaps, and we refer you for hyperbaric oxygen.
When surgery is the step that saves the foot
Some ulcers don’t heal with good non-surgical care because dressings and devices can’t reach the cause: a deep infection, infected bone, or a bony bump or tight tendon loading the same spot with every step. The infection and offloading guidelines both include surgery for these situations.[9,1] Dr. Ozturk performs limb salvage surgery for the diabetic foot, including draining infection, removing dead tissue and infected bone, correcting deformities that cause ulcers, and Charcot reconstruction. The Center for Lower Extremity Surgery also covers the surgical side of diabetic foot ulcers (external site).
Clearing infection. After surgery for a diabetic foot infection that cleans out infected bone, a shorter antibiotic course may be enough.[10] In a randomized pilot trial of 93 people with a diabetic foot bone infection, three weeks of antibiotics worked about as well as six.[10] Remission rates were 84% with three weeks and 73% with six.[10]
Taking pressure off the ulcer. If non-surgical offloading fails to heal an ulcer on the sole under the forefoot, the offloading guideline advises considering surgery. The options are an Achilles tendon lengthening, removing a metatarsal head, reshaping a joint (arthroplasty) or realigning a metatarsal bone (osteotomy).[1] For an ulcer on the tip or underside of a flexible bent smaller toe, it recommends a small toe-tendon release (digital flexor tenotomy).[1] Combined with an offloading device, each tendon procedure likely heals more ulcers, and keeps more of them healed, than the device alone, though each was tested in only one small trial.[4]
In a randomized trial of 64 people with a forefoot ulcer and limited ankle motion, most ulcers healed in a cast either way: all 30 with an Achilles tendon lengthening and 88% without it.[5] By about two years, 38% had come back after the lengthening versus 81% without it.[5]
Dr. Ozturk performs these operations that take pressure off ulcers, and removes bony prominences under ulcers (exostectomy), for the ulcers that need them. If you’ve been told you need an amputation, a second opinion before amputation can help you understand your options.
What surgery can and can’t do
Surgery works alongside offloading, infection control and blood flow, not instead of them. Surgery to take pressure off an ulcer isn’t done while blood flow to the foot is severely reduced.[1] In a study of 1,465 foot and ankle operations, infection at the surgical site followed 9.5% of operations in people with diabetes and 2.4% in people without it.[11] Nerve damage, Charcot changes and smoking were linked to infection.[11] Tendon procedures can shift pressure elsewhere: toe-tendon releases may cause new transfer lesions, and Achilles lengthening likely increases new heel ulcers.[4] The evidence behind these offloading treatments, surgical or not, is of low to moderate certainty.[4] We go over these trade-offs with you before any operation.
After it heals: keeping the foot in remission
Once an ulcer heals, the foot is in remission, but recurrence is common: an estimated 42% of people develop another ulcer within a year after healing, and 65% within five years.[8] To prevent recurrence, the prevention guideline recommends therapeutic footwear with a demonstrated pressure-relieving effect, integrated foot care for people at moderate to high risk, and treatment of any pre-ulcer sign.[12]
At our practice, keeping your foot in remission means therapeutic shoes and custom inserts, check-ups scheduled by your level of risk, and early care for any callus or warm spot. The Ozturk Foot & Ankle diabetic foot care page (external site) covers daily foot checks and protective footwear.
When to seek care
About 80% of leg and foot amputations in people with diabetes follow a foot ulcer, so we would rather see a wound early.[8] See us within a day or two for any foot wound that isn’t healing, especially if you have diabetes.
References
- 1.Bus SA, Armstrong DG, Crews RT, Gooday C, Jarl G, Kirketerp-Moller K, et al. Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3647. PubMed 37226568 (external site)
- 2.National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes and Foot Problems. niddk.nih.gov (external site)
- 3.Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, et al. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes and a foot ulcer. Diabetes Metab Res Rev. 2024;40(3):e3686. PubMed 37726988 (external site)
- 4.Lazzarini PA, Armstrong DG, Crews RT, et al. Effectiveness of offloading interventions for people with diabetes-related foot ulcers: A systematic review and meta-analysis. Diabetes Metab Res Rev. 2024;40(3):e3650. PubMed 37292021 (external site)
- 5.Mueller MJ, Sinacore DR, Hastings MK, et al. Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. J Bone Joint Surg Am. 2003;85(8):1436-45. PubMed 12925622 (external site)
- 6.Monteiro-Soares M, Hamilton EJ, Russell DA, et al. Guidelines on the classification of foot ulcers in people with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3648. PubMed 37179483 (external site)
- 7.Chen P, Vilorio NC, Dhatariya K, Jeffcoate W, Lobmann R, McIntosh C, et al. Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3644. PubMed 37232034 (external site)
- 8.Armstrong DG, Tan TW, Boulton AJM, et al. Diabetic Foot Ulcers: A Review. JAMA. 2023;330(1):62-75. PubMed 37395769 (external site)
- 9.Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, et al. IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023). Diabetes Metab Res Rev. 2024;40(3):e3687. PubMed 37779323 (external site)
- 10.Gariani K, Pham TT, Kressmann B, et al. Three Weeks Versus Six Weeks of Antibiotic Therapy for Diabetic Foot Osteomyelitis: A Prospective, Randomized, Noninferiority Pilot Trial. Clin Infect Dis. 2021;73(7):e1539-e1545. PubMed 33242083 (external site)
- 11.Wukich DK, McMillen RL, Lowery NJ, Frykberg RG. Surgical site infections after foot and ankle surgery: a comparison of patients with and without diabetes. Diabetes Care. 2011;34(10):2211-3. PubMed 21816974 (external site)
- 12.Bus SA, Sacco ICN, Monteiro-Soares M, Raspovic A, Paton J, Rasmussen A, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3651. PubMed 37302121 (external site)
This page is general health information and isn’t a substitute for advice from a clinician who knows your history. Read our medical disclaimer and how we review content.
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Related topics
Treatment
Total contact casting
A knee-high cast or locked walker you can’t take off, which spreads pressure away from a foot ulcer so it can heal.
Treatment
Wound debridement
Removing callus and dead tissue from a foot wound, in the office or the operating room, so the wound can heal.
Treatment
Offloading surgery
Operations on the calf, Achilles or toe tendons (and sometimes a metatarsal bone) that take pressure off an ulcer so it heals and is less likely to come back.
Condition
Diabetic foot infections
An infection of the skin, deeper tissue or bone of the foot in a person with diabetes, usually starting in a wound.
Condition
After an ulcer heals
How to keep a healed diabetic foot ulcer from coming back, from protective shoes and daily checks to surgery that reduces the pressure behind it.