In Germany, diabetic Foot Ulcer is managed by podiatrys. Diabetic foot ulcer is a full-thickness break in the skin of the foot in a person with diabetes mellitus, almost always developing through the combination of peripheral neuropathy, peripheral arterial disease, repetitive plantar pressure, and minor trauma that goes unnoticed because of insensate feet. Roughly 19-34% of people with diabetes will develop a foot ulcer over their lifetime and 1-4% develop a new ulcer each year.
Diabetic foot ulcer (ICD-10: L97 chronic ulcer of lower limb; E11.621 type 2 diabetes mellitus with foot ulcer) is a localized full-thickness skin break, typically on the plantar foot or toes, in a person with diabetes mellitus. The pathophysiology rests on three convergent processes: peripheral neuropathy (loss of pain, pressure, and proprioceptive sensation), peripheral arterial disease (impaired tissue perfusion), and biomechanical abnormalities (rigid foot deformities, equinus contracture, prominent metatarsal heads) that concentrate plantar pressure over insensate skin. Repeated low-grade trauma in the absence of protective sensation produces tissue damage that progresses from callus to subcutaneous hematoma to skin break. Once a break occurs, impaired immunity and elevated glucose support polymicrobial colonization, and ulcers commonly become infected, complicated by osteomyelitis, or undermined by underlying necrotic tissue.
The key symptoms of Diabetic Foot Ulcer are: A wound or sore on the foot that the patient may not have noticed because of insensate skin — typically discovered during routine self-examination or by a relative., Callus formation over a bony prominence, often with a darker discoloration suggesting subcutaneous hematoma before frank ulceration., Drainage staining socks or shoe lining (serosanguinous in early ulcers; cloudy, foul, or purulent if infected)., Redness, warmth, swelling, and tenderness around the ulcer suggesting cellulitis; absence of pain does not exclude infection in neuropathic feet., Foul odor from anaerobic infection, particularly in deep or chronic ulcers., Visible bone or tendon in the ulcer base — strongly associated with osteomyelitis., Dusky or black tissue (eschar, gangrene) at the ulcer edges or distal toes — vascular emergency..
Diagnosis is clinical with structured assessment. Examination begins with footwear and sock inspection, then full foot exam: vascular (femoral, popliteal, dorsalis pedis, posterior tibial pulses; ankle-brachial index or toe-brachial index when pulses absent or vessels calcified), neurological (10 g monofilament at 10 plantar sites, 128 Hz tuning fork at hallux, deep tendon reflexes), and structural (deformities, callus, skin condition, web spaces). Each ulcer is measured (length × width × depth), photographed, and probed: a probe-to-bone test that touches bone has a positive predictive value of about 90% for osteomyelitis in moderate-to-severe diabetic foot infections. Bone tissue is taken for culture (gold standard) rather than superficial swabs which give misleading polymicrobial growth. Plain radiographs assess for cortical erosion, periosteal reaction, gas in tissues, or sequestrum. MRI is the imaging gold standard for osteomyelitis with sensitivity 90% and specificity 80%. White-cell-tagged single-photon emission CT (SPECT-CT) is used when MRI is contraindicated. Wagner, University of Texas, IWGDF SINBAD, and the IWGDF/IDSA infection classification (mild/moderate/severe) all guide management. Ankle-brachial index below 0.9 raises suspicion of PAD; below 0.5 indicates severe ischemia. Transcutaneous oxygen pressure (TcPO2) below 30 mmHg, toe systolic pressure below 30 mmHg, or skin perfusion pressure below 40 mmHg predict non-healing and prompt revascularization assessment. Glycemic control, kidney function, nutritional status (albumin, prealbumin, vitamin D, B12) and HbA1c are reviewed. Wound cultures direct antibiotic choice. Bone biopsy guides antibiotic selection and duration in suspected osteomyelitis.
Outlook depends on ulcer location, depth, infection, ischemia, and adherence to multidisciplinary care. Approximately 60-80% of diabetic foot ulcers heal within 20 weeks with appropriate care. However, recurrence rates are high: 40% at 1 year, 60% at 3 years, and 65% at 5 years. Mortality is sobering — 5-year mortality after a diabetic foot ulcer is 30-40%, higher than most common cancers, driven by cardiovascular disease and renal complications shared with the underlying diabetes. Approximately 20% of patients with a diabetic foot ulcer eventually require an amputation; major amputation (above-ankle) carries 1-year mortality of 20-30% and 5-year mortality of 50-70%. Predictors of better outcome: shorter ulcer duration before specialist referral, absence of infection and ischemia, smaller ulcer area, intact protective sensation, and adherence to offloading. Multidisciplinary diabetic foot programs reduce major amputation by 40-85% in cohort studies.
Refer to a multidisciplinary diabetic foot clinic at first sign of foot ulceration, deformity development, or pre-ulcerative callus. Vascular surgery referral is needed when ABI is under 0.9, TcPO2 under 30 mmHg, or non-healing persists. Infectious disease input is essential for moderate or severe infection and confirmed osteomyelitis. Plastic and orthopedic surgery consultation guides complex reconstruction. Coordinated specialty care reduces major amputation by 40-85% in published cohorts.
Find specialists →Granulation tissue typically appears within 2-4 weeks of consistent offloading and debridement. Median time to wound closure is 9-13 weeks for uncomplicated neuropathic ulcers and longer for infected or ischemic ulcers. Once healed, patients transition to therapeutic footwear with custom insoles. Lifetime surveillance is needed — recurrence prevention requires podiatry follow-up every 1-3 months, daily foot inspection, and adherence to footwear protocols.
During active ulceration, avoid weight-bearing exercise on the affected foot. Upper-body resistance training, seated stationary cycling with the unaffected leg, and swimming (only if no open wound — once healed) are alternatives. Once the ulcer heals and patient is in protective footwear, gradual return to walking and supervised exercise improves glycemic control and cardiovascular risk. Patients with PAD benefit from supervised exercise programs, which improve walking distance by 100-200% over 12-24 weeks. Patients with severe neuropathy need particular caution: blisters or stress fractures can occur silently.
Choose a podiatrist or vascular surgeon affiliated with a dedicated diabetic foot clinic that integrates podiatry, vascular surgery, endocrinology, infectious disease, plastic surgery, and orthotics. Ask whether they routinely use total contact casting, perform on-site monofilament screening and ABI/TBI, have rapid access to revascularization, and report limb-salvage outcomes. Continuity matters: follow-up should be lifelong because recurrence rates exceed 50% within 3 years.
Medically reviewed by AIHealz Medical Editorial Board · May 13, 2026
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