Condition
Peripheral artery disease and foot wounds (limb-threatening ischemia)
Narrowed leg arteries that starve a foot wound of blood, and the vascular procedures and foot surgery that aim to restore circulation, heal the wound and keep the foot.
Medically reviewed by Dr. Efe Ozturk · Last reviewed
Watch: Peripheral artery disease and foot wounds explained
Read the transcript
Peripheral artery disease, or PAD, is plaque buildup that reduces blood flow to the legs and feet. About half of people with diabetes and a foot ulcer have PAD, and nerve damage can hide its warning pain. Three arteries below the knee supply the foot and ankle: the anterior tibial, the posterior tibial and the peroneal. With diabetes, plaque tends to block these arteries over long stretches, often in both legs, with fewer natural detours. So a foot wound may heal slowly, or not at all. When the foot itself lacks blood, look for pain at rest, often worse at night and eased by hanging the foot down. Other signs are sores that won’t heal, a foot that turns pale when raised and red when lowered, and a colder foot. Gangrene, tissue that has died from lack of blood, usually appears on the forefoot. When PAD causes rest pain, gangrene or a sore open more than 2 weeks, it is called chronic limb-threatening ischemia, or CLTI. We start with your history and foot pulses, and do noninvasive circulation testing at our practice. Doppler waveforms and the ankle-brachial and toe-brachial indexes are added, because no single test rules PAD out. Stiff leg arteries, common with diabetes or kidney disease, can make the ankle reading falsely high; in CLTI, toe pressures are preferred. With a foot ulcer, a toe pressure under 30 mmHg, or an ankle-brachial index under 0.4, calls for an urgent vascular consultation. Restoring blood flow is the central treatment for CLTI, and vascular specialists do it. Balloon angioplasty opens the artery from inside, sometimes adding a small mesh tube called a stent. Bypass surgery builds a new path around the blockage, ideally using one of your own veins. Either way, the aim is a straight path of blood to at least one artery of the foot. We refer you to a vascular specialist and plan your foot surgery around their work. Better blood flow alone does not always heal the foot. When the foot is also infected, draining a deep infection or abscess usually comes first. After blood flow is restored, most people with gangrene of the foot are evaluated for a toe or partial foot amputation. The goal is a working foot that fits in a shoe, keeping as much tissue as possible. Dr. Ozturk, a Foot and Ankle Surgeon board certified in wound care, drains infection and removes dead tissue and infected bone. For the feet that need it, he performs toe, ray, transmetatarsal or midfoot amputations. A wound VAC can help heal a wound that can’t be stitched closed, and we use one when a wound needs it. Every week or two, we measure the wound, clear dead tissue and take pressure off it, until it has fully closed. With diabetes and a foot ulcer, most studies report that a year after restoring blood flow, 80–85% still have their leg. And more than 60% of those ulcers have healed. Restoring blood flow carries real risk: about 2 in 100 people with diabetes do not survive the first 30 days. After a diabetic foot ulcer heals, an estimated 42% return within a year, so follow-up matters. See us within a day or two for any foot wound that isn’t healing, especially if you have diabetes, even if it doesn’t hurt. If your foot or toes suddenly turn cold, pale or blue, call 911 or go to the emergency department. Do the same for black tissue, spreading redness with fever, foul-smelling drainage, or if you feel unwell. Dr. Ozturk treats foot wounds 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 poor circulation holds a wound back
Peripheral artery disease is caused mainly by atherosclerosis: plaque builds up inside the arteries and slows the flow of oxygen-rich blood. Age, smoking, diabetes, chronic kidney disease, high blood pressure and unhealthy cholesterol levels all raise the risk.[1]
Three arteries below the knee supply the foot and ankle: the anterior tibial, the posterior tibial and the peroneal.[3] With diabetes, PAD tends to block these arteries over long stretches, often in both legs, with fewer natural detours around the blockages, so a wound may heal slowly or not at all.[3,1]
Swipe sideways to see the whole drawing.
You may also hear “critical limb ischemia,” an older term that guidelines have replaced because limb threat is a continuum.[2]
Warning signs
The most common PAD symptom is calf, thigh or buttock cramping that comes on with walking and eases with rest.[1] When the foot itself lacks blood, look for:
- Pain at rest in the forefoot and toes, often worse at night or lying flat and eased by hanging the foot down.[2] See foot pain at night.
- Sores that won’t heal, often on the toes and forefoot.[2]
- Color changes: a foot that turns pale when raised and red when lowered, or skin that looks discolored or blue.[2,1] See dark, black or blue toes.
- A colder foot, or toenails and leg hair that stop growing.[1]
- Gangrene, tissue that has died from lack of blood, usually on the forefoot (see gangrene).[2]
With diabetes, nerve damage and being less active can hide both walking pain and rest pain.[3] Nerves or circulation? See cold feet or numb feet (external site) at our sister practice.
How blood flow is tested
For anyone with diabetes and a foot ulcer or gangrene, the check starts with your history and foot pulses.[3] Doppler waveforms and the ankle- and toe-brachial indexes are added, because no single test is ideal and no single result rules PAD out.[3] Stiff leg arteries, common with diabetes or kidney disease, can make the ankle reading falsely high; toe arteries rarely stiffen this way.[4] In CLTI, toe pressures are the preferred measure.[2]
We check your pulses and do noninvasive circulation testing at our practice. Before a procedure, duplex ultrasound, CT or MR angiography, or an angiogram maps the arteries down to the foot;[3] we arrange this with vascular specialists. See circulation tests for foot wounds.
With a foot ulcer, a toe pressure under 30 mmHg or an ankle-brachial index under 0.4 signals severe ischemia and calls for an urgent vascular consultation.[3] In people with diabetes, waiting more than two weeks to restore blood flow has been linked to a higher risk of limb loss.[3] A wound that hasn’t shrunk by about half after 4 weeks of good care is another reason to recheck circulation with a vascular specialist.[3]
Specialists stage the threat with the WIfI system, which grades the Wound, Ischemia and foot Infection from 0 to 3.[5,3] Higher stages are linked to slower healing and a higher one-year risk of major amputation.[3]
Restoring blood flow
Revascularization aims to heal wounds, relieve pain and keep a working limb.[4] It is done from inside the artery with a balloon (angioplasty), sometimes adding a small mesh tube (stent), or with bypass surgery that builds a new path around the blockage, ideally from one of your own veins.[1,4]
The choice depends on where the blockages are, whether a good vein is available, your health and preferences.[4] With diabetes, a foot ulcer and a good leg vein, the diabetic foot guideline suggests bypass first when either procedure is possible.[3] Either way, the aim is a straight path of blood to at least one artery of the foot.[3]
We refer you to a vascular specialist, share what we see in the wound and plan your foot surgery around their work. See restoring blood flow.
When the foot is also infected, draining an abscess or deep infection usually comes first, with antibiotics adjusted to tissue cultures.[3] Once the infection is controlled, restoring blood flow within a few days should be considered if circulation is badly reduced.[3] See diabetic foot infections.
Everyone with CLTI should also get full medical treatment: medicines that prevent clots, lower cholesterol and control blood pressure and blood sugar, plus help to stop smoking.[2]
How surgery helps save the foot
Better blood flow alone does not always heal the foot. A shallow ulcer without infection may heal once circulation improves.[4] Deeper infection or tissue loss may need damaged tissue or bone removed and the wound closed, at once or in stages.[4] Once blood flow is better and infection is controlled, a final operation may rebuild soft tissue and bone for a working foot.[3] After blood flow is restored, most people with gangrene of the foot are evaluated for a toe or partial foot amputation.[4] The goal is a working foot that fits in a shoe, keeping as much tissue as possible.[4]
Dr. Efe Ozturk, a Foot and Ankle Surgeon, is board certified in wound care (FAPWH). He drains infection, removes dead tissue and infected bone and, for the feet that need it, performs toe, ray, transmetatarsal or midfoot amputations. After revascularization and a toe or partial foot amputation, negative-pressure wound therapy can help heal a wound that can’t be stitched closed, either right away or later.[4] We use a wound VAC for the wounds that need it. See toe and partial foot amputation and limb salvage surgery.
Wound care and restoring blood flow go hand in hand until the wound has fully closed, because the risk of a limb-threatening infection lasts until then.[4] Every week or two, we measure the wound, clear dead tissue and take pressure off it (see wound care visits). Treated arteries can narrow again, so circulation is rechecked after the procedure and whenever healing stalls.[3]
Risks and limits. Restoring blood flow carries real risk: in people with diabetes, about 2 in 100 do not survive the first 30 days after either type of procedure, more with end-stage kidney disease.[3] It is not advised when success is very unlikely, and evidence on how much it helps healing and prevents amputation is of low certainty.[3] Before any major amputation, a team should review every option for restoring blood flow, unless a life-threatening infection makes that unsafe.[4] If a below-knee amputation is ever needed, a vascular or orthopedic surgeon performs it. See a second opinion before amputation.
Outlook after healing
After a diabetic foot ulcer heals, an estimated 42% return within a year and 65% within five years, so follow-up matters.[6] After a toe or partial foot amputation, the US PAD guideline recommends follow-up wound care, offloading and therapeutic footwear to prevent new wounds.[4] We offer risk-based foot check-ups, therapeutic shoes and custom inserts. See keeping your foot in remission and our parent practice’s guide to poor circulation in the feet (external site).
When to seek care
See us within a day or two for any foot wound that isn’t healing, especially if you have diabetes, even if it doesn’t hurt.
References
- 1.National Heart, Lung, and Blood Institute. Peripheral Artery Disease. NIH. nhlbi.nih.gov (external site)
- 2.Conte MS, Bradbury AW, Kolh P, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg. 2019;69(6S):3S-125S.e40. PubMed 31159978 (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.Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, et al. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149(24):e1313-e1410. PubMed 38743805 (external site)
- 5.Mills JL Sr, Conte MS, Armstrong DG, et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg. 2014;59(1):220-34.e1-2. PubMed 24126108 (external site)
- 6.Armstrong DG, Tan TW, Boulton AJM, et al. Diabetic Foot Ulcers: A Review. JAMA. 2023;330(1):62-75. PubMed 37395769 (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.
Questions patients ask
Articles from our blog on healing a wound, protecting the foot and the surgery that saves it, with the sources listed.
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Related topics
Treatment
Restoring blood flow
Angioplasty, stents and bypass, performed by vascular specialists, restore blood flow to a foot wound that is starved of it; we test circulation, refer you and time foot surgery and wound care around the procedure.
Diagnosis guide
Circulation tests
How ankle and toe pressures, Doppler waveforms, TcPO2 and artery imaging measure blood flow to a foot wound, and how the results guide healing, surgery and vascular referral.
Symptom guide
Foot pain at night
How to recognize ischemic rest pain, a warning sign of severely narrowed leg arteries, tell it apart from diabetic nerve pain and night cramps, and get help quickly.
Condition
Gangrene
Toe or foot tissue that has died from poor blood flow, infection or injury, and the care that aims to save the rest of the foot.
Treatment
Partial foot amputation
Surgery that removes only the part of the foot that can’t heal, from a single toe to the midfoot, keeping as much of the foot as is safe, to help you keep walking.