Diabetic Foot Ulcers Clinical Presentation

Updated: Oct 15, 2020
  • Author: Tanzim Khan, DPM; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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The history should focus on the signs and symptoms of a diabetic foot ulcer or pre-ulcerative lesion. Symptoms indicative of possible peripheral neuropathy or peripheral arterial insufficiency should also be investigated.

In the diagnosis of diabetic foot ulcers or pre-ulcerative lesions, the following should be taken into account:

  • History of trauma
  • History of puncture wound (with or without shoe gear)
  • History of change in shoe gear
  • History of deformity, either acquired or congenital
  • History of callus or blister
  • History of wound care management
  • History of offloading
  • Local signs of infection
  • Systemic signs of infection

Symptoms of peripheral neuropathy

The symptoms of peripheral neuropathy include the following:

  • Hypoesthesia

  • Hyperesthesia

  • Paresthesia

  • Dysesthesia

  • Radicular pain

  • Anhidrosis

Symptoms of peripheral arterial insufficiency

Most people harboring atherosclerotic disease of the lower extremities are asymptomatic; others develop ischemic symptoms. Some patients attribute ambulatory difficulties to old age and are unaware of the existence of a potentially correctible problem.

Patients who are symptomatic may present with intermittent claudication, ischemic pain at rest, nonhealing ulceration of the foot, or frank ischemia of the foot.

Cramping or fatigue of major muscle groups in one or both lower extremities that is reproducible upon walking a specific distance suggests intermittent claudication. This symptom increases with ambulation until walking is no longer possible, and it is relieved by resting for several minutes. The onset of claudication may occur sooner with more rapid walking or walking uphill or up stairs.

The claudication of infrainguinal occlusive disease typically involves the calf muscles. Discomfort, cramping, or weakness in the calves or feet is particularly common in the diabetic population because they tend to have tibioperoneal atherosclerotic occlusions. Calf muscle atrophy may also occur. Symptoms that occur in the buttocks or thighs suggest aortoiliac occlusive disease.

Rest pain is less common in the diabetic population. In some cases, a fissure, ulcer, or other break in the integrity of the skin envelope is the first sign that loss of perfusion has occurred. When a diabetic patient presents with gangrene, it is often the result of infection.


Physical Examination

Physical examination of the extremity that has a diabetic ulcer can be divided into different categories:

  • Examination of ulceration

  • Examination of the feet

  • Assessment of the possibility of vascular insufficiency [4]

  • Assessment for the possibility of peripheral neuropathy

Remember that diabetes is a systemic disease. Hence, a comprehensive physical examination of the entire patient is also vital.

Examination of ulceration

Accomplish the following in examination of ulceration

  • Determine the location of the ulceration, as ulcers are typically located around bony prominences and weight-bearing surfaces; typical locations include the dorsal interphalangeal joints of hammertoes and distal tips of digits, below metatarsal heads in claw toes, the medial and lateral forefoot in patients with bunions and bunionettes, plantar lateral wounds in Charcot foot, and the lateral foot and lateral malleoli in varus deformities
  • Measure the size, including the depth of the wound
  • Describe the wound base (granular, fibrotic, necrotic, eschar)
  • Inspect for probing to bone
  • Inspect for any undermining or tunneling of the wound
  • Describe any drainage
  • Describe the periwound area (maceration, hyperkeratotic tissue)

Examination of feet 

Carry out the following in foot examination [33] :

  • Inspect the static posture of the feet on the examination table, as well as when weight-bearing.
  • ​Assess for gross deformities and determine if they are reducible or rigid
  • Assess ankle range of motion using the Silfverskiöld test - If there is limited ankle dorsiflexion (cannot pass neutral) with the knee both flexed and extended, it is considered gastrocsoleal tightness; if there is increased dorsiflexion with the knee flexed, however limited with the knee in extension, it is considered gastrocnemius equinus 
  • Assess range of motion at the interphalangeal joints, metatarsophalangeal joints, midtarsal joints, and subtalar joints
  • Evaluate muscle power of dorsiflexors, plantar flexors, invertors, and evertors to identify any muscular imbalances
  • Examine the skin for dryness and fissures, as well as for discrete calluses; hemorrhagic calluses in particular are a sign of impending foot ulceration.

Assessment of possible peripheral arterial insufficiency

Physical examination discloses absent or diminished peripheral pulses below a certain level.

Although diminished common femoral artery pulsation is characteristic of aortoiliac disease, infrainguinal disease alone is characterized by normal femoral pulses at the level of the inguinal ligament and diminished or absent pulses distally. Specifically, loss of the femoral pulse just below the inguinal ligament occurs with a proximal superficial femoral artery occlusion. Loss of the popliteal artery pulse suggests superficial femoral artery occlusion, typically in the adductor canal.

Loss of pedal pulses is characteristic of disease of the distal popliteal artery or its trifurcation. However, be aware that absence of the dorsalis pedis pulse may be a normal anatomic variant that is noted in about 10% of the pediatric population. On the other hand, the posterior tibial pulse is present in 99.8% of persons aged 0-19 years. Hence, absence of both pedal pulses is a more specific indicator of peripheral arterial disease.

Other findings suggestive of atherosclerotic disease include a bruit heard overlying the iliac or femoral arteries, skin atrophy, loss of pedal hair growth, cyanosis of the toes, ulceration or ischemic necrosis, and pallor of the involved foot followed by dependent rubor after 1-2 minutes of elevation above heart level.

Assessment of possible peripheral neuropathy

Signs of peripheral neuropathy include loss of vibratory and position sense, loss of deep tendon reflexes (especially loss of the ankle jerk), trophic ulceration, foot drop, muscle atrophy, and excessive callous formation, especially overlying pressure points such as the heel.

The nylon monofilament test helps diagnose the presence of sensory neuropathy. [34] A 10-gauge monofilament nylon is pressed against each specific site of the foot just enough to bend the wire. If the patient does not feel the wire at 4 or more of these 10 sites, the test is positive for neuropathy. General use filaments can be obtained from the National Institute of Diabetes and Digestive and Kidney Diseases, or the clinician can use professional Semmes-Weinstein filaments.