Management of the Diabetic Foot

  • John M. Giurini
  • Barry I. Rosenblum
  • Thomas E. Lyons
Part of the Contemporary Endocrinology book series (COE, volume 7)


Limb salvage, when dealing with the diabetic foot, deals with the ability to avoid amputation. This goal is carried out through three main aspects of diabetic care: identification of the “at-risk” foot, successful treatment of the acutely involved foot, and prevention of further problems. At each of these junctures patient education plays a vital role. A comprehensive program of diabetic foot management must include each of these aspects to successfully achieve limb salvage.


Limb Salvage Plantar Pressure Metatarsal Head Aldose Reductase Inhibitor Orthotic Device 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Thomson FJ, Veves A, Ashe H, Knowles EA, Gem J, Walker MG, Hirst P, Boulton AJM. A team approach to diabetic foot care-the Manchester experience. Foot 1991;1:75–82.CrossRefGoogle Scholar
  2. 2.
    Edmonds ME, Blundell MP, Morris HE, Maelor-Thomas E, Cotton LT, Watkins PJ. Improved survival of the diabetic foot: the role of the specialist foot clinic. Q J Med 1986;232:763–771.Google Scholar
  3. 3.
    Wagner FW. The dysvascular foot: a system for diagnosis and treatment. Foot Ankle 1981;2:64–122.PubMedGoogle Scholar
  4. 4.
    Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996;35:528–531.PubMedCrossRefGoogle Scholar
  5. 5.
    Young MJ, Veves A, Boulton AJM. The diabetic foot: aetiopathogenesis and management. Diab/Metab Rev 1993;9:109–127.CrossRefGoogle Scholar
  6. 6.
    Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. N Engl J Med 1994;331:854–860.CrossRefGoogle Scholar
  7. 7.
    Kumar S, Fernando DJS, Veves A, Knowles EA, Young MJ, Boulton AJM. Semmes-Weinstein monofilaments: a simple, effective and inexpensive screening device for identifying diabetic patients at risk of foot ulceration. Diab Res Clin Pract 1991;13:63–68.CrossRefGoogle Scholar
  8. 8.
    Sosenko JM, Kato M, Soto R, Bild DE. Comparison of quantitative sensory-threshold measures for their association with foot ulceration in diabetic patients. Diab Care 1990;13:1057–1061.CrossRefGoogle Scholar
  9. 9.
    Young MJ, Breddy JL, Veves A, Boulton AJM. The prediction of diabetic foot ulceration using vibration thresholds: a prospective study. Diabetes Care 1994;17:557–560.PubMedCrossRefGoogle Scholar
  10. 10.
    Ewing DJ, Martyn CN, Young RJ, Clarke BF. The value of cardiovascular autonomic function tests: 10 years experience in diabetes. Diab Care 1985;8:491–498.CrossRefGoogle Scholar
  11. 11.
    Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes. N Engl J Med 1994;331:854–860.PubMedCrossRefGoogle Scholar
  12. 12.
    Young MJ, Taylor PM, Boulton AJM. A new, non-invasive technique to predict foot ulcer risk. Diabetes 1993;42(suppl 1):A632.Google Scholar
  13. 13.
    Tovey FE. The manufacture of diabetic footwear. Diab Med 1984;1:69–71.CrossRefGoogle Scholar
  14. 14.
    Tovey FE, Moss MJ. Specialist shoes for the diabetic foot. In: Connor H, Boulton AJM, Ward JD, eds. The Foot in Diabetes. Wiley, Chichester, UK, 1987, pp. 97–108.Google Scholar
  15. 15.
    Rosen RC, Davids MS, Bohanski LM. Hemorrhage into plantar callus and diabetes mellitus. Cutis 1985;35:339–341.PubMedGoogle Scholar
  16. 16.
    Harkless LB, Dennis KJ. You see what you look for and recognize what you know. Clin Pod Med Surg 1987;4:331–339.Google Scholar
  17. 17.
    Delbridge L, Perry P, Marr S, Arnold N, Yue DK, Turtle JR, Reeve TS. Limited joint mobility in the diabetic foot: relationship to neuropathic ulceration. Diabetic Med 1988;5:333–337.PubMedCrossRefGoogle Scholar
  18. 18.
    Fernando DJS, Masson EA, Veves A, Boulton AJM. Relationship of limited joint mobility to abnormal foot pressures and diabetic foot ulceration. Diabetes Care 1991;14:8–11.PubMedCrossRefGoogle Scholar
  19. 19.
    Veves A, Fernando DJS, Walewski P, Boulton AJM. A study of plantar pressures in a diabetic clinic population. Foot 1991;1:89–92.CrossRefGoogle Scholar
  20. 20.
    Olmos PR, Cataland S, O’Dorisio TM, Casey CA, Smead WL, Simon SR. The Semmes-Weinstein monofilament as a potential predictor of foot ulceration in patients with noninsulin-dependent diabetes. Am J Med Sci 1995;309:76–82.PubMedCrossRefGoogle Scholar
  21. 21.
    Veves A, Masson EA, Fernando DJS, Boulton AJM. Use of experimental padded hosiery to reduce foot pressures in diabetic neuropathy. Diabetes Care 1989;12:653–655.PubMedCrossRefGoogle Scholar
  22. 22.
    Veves A, Masson EA, Fernando DJS, Boulton AJM. Studies of experimental hosiery in diabetic neuropathic patients with high foot pressures. Diabetic Med 1990;7:324–326.PubMedCrossRefGoogle Scholar
  23. 23.
    Young MJ, Cavanagh PR, Thomas G, Johnson MM, Murray H, Boulton AJM. The effect of callus removal on dynamic plantar pressures in diabetic patients. Diabetic Med 1992;9:55–57.PubMedCrossRefGoogle Scholar
  24. 24.
    Joseph WS, Axler DA. Microbiology and antimicrobial therapy of diabetic foot infections. Clin Pod Med Surg 1990;7:467–481.Google Scholar
  25. 25.
    Pollard JP, LeQuesne LP. Methods of healing diabetic forefoot ulcers. Br Med J 1983;286:436–437.CrossRefGoogle Scholar
  26. 26.
    Burden AC, Jones GR, Jones R, Blandford RL. Use of the Scotchcast boot in treating diabetic foot ulcers. Br Med 1983;286:1555–1557.CrossRefGoogle Scholar
  27. 27.
    Coleman WC, Brand PW, Birke JA. The total contact cast: a therapy for plantar ulcerations on insensitive feet. J Am Podiatry Assoc 1984;74:548–552.PubMedGoogle Scholar
  28. 28.
    Mueller MJ, Diamond JE, Sinacore DR. Total contact casting in treatment of diabetic plantar ulcers. Diab Care 1989;12:384–388.CrossRefGoogle Scholar
  29. 29.
    Kucan JO, Robson MC, Heggers JP, Ko F. Comparison of silver sulfadiazine, povidone-iodine and physiologic saline in the treatment of chronic pressure ulcers. J Am Geriatr Soc 1981;29:232–235.PubMedGoogle Scholar
  30. 30.
    Lineweaver W, Howard R, Soucy D, et al. Topical antimicrobial activity. Arch Surg 1985;120: 267–270.CrossRefGoogle Scholar
  31. 31.
    Gudas CJ. Prophylactic surgery in the diabetic foot. Clin Podiatr Med Surg 1987;4:445–458.PubMedGoogle Scholar
  32. 32.
    Tillo TH, Giurini JM, Habershaw GM, Chrzan JS, Rowbotham JL. Review of metatarsal osteotomies for the treatment of neuropathic ulcerations. J Am Podiatr Med Assoc 1990;80:211–217.PubMedGoogle Scholar
  33. 33.
    Jacobs RL. Hoffman procedure in the ulcerated diabetic neuropathic foot. Foot Ankle 1982;3:142–149.PubMedGoogle Scholar
  34. 34.
    Giurini JM, Basile P, Chrzan JS, Habershaw GM, Rosenblum BI. Panmetatarsal head resection: a viable alternative to the transmetatarsal amputation. J Am Podiatr Med Assoc 1993;83:101–107.PubMedGoogle Scholar
  35. 35.
    Giurini JM, Rosenblum BI. The role of foot surgery in patients with diabetes. Clin Podiatr Med Surg 1995;12:119–127.PubMedGoogle Scholar
  36. 36.
    Rosenblum BI, Giurini JM, Chrzan JS, Habershaw GM. Preventing loss of the great toe with the hallux interphalangeal joint arthroplasty. J Foot Ankle Surg 1994;33:557–560.PubMedGoogle Scholar
  37. 37.
    Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW. Probing to bone in infected pedal ulcers: a clinical sign of underlying osteomyelitis in diabetic patients. JAMA 1995;273:721–723.PubMedCrossRefGoogle Scholar
  38. 38.
    Gibbons GW. The diabetic foot: amputations and drainage of infection. J Vasc Surg 1987;5:791–793.PubMedGoogle Scholar
  39. 39.
    Wheat LJ, Allen SD, Henry M, et al. Diabetic foot infections: bacteriologic analysis. Arch Intern Med 1986;146:1935–1940.PubMedCrossRefGoogle Scholar
  40. 40.
    Taylor LM, Porter JM. The clinical course of diabetic patients who require emergent foot surgery because of infection or ischemia. J Vasc Surg 1987;6:454–459.PubMedGoogle Scholar
  41. 41.
    LoGerfo FW, Gibbons GW, Pomposelli FB Jr, et al. Trends in the care of the diabetic foot: expanded role of arterial reconstruction. Arch Surg 1992;127:617–621.PubMedCrossRefGoogle Scholar
  42. 42.
    Newman LG, Waller J, Palestro CJ, et al. Unsuspected osteomyelitis in diabetic foot ulcers: diagnosis and monitoring by leukocyte scanning with indium in 111 oxyquinoline. JAMA 1991;266:1246–1251.PubMedCrossRefGoogle Scholar
  43. 43.
    Keenan AM, Tindel NL, Alavi A. Diagnosis of pedal osteomyelitis in diabetic patients using current scintigraphic techniques. Arch Intern Med 1989;149:2262–2266.PubMedCrossRefGoogle Scholar
  44. 44.
    Hetherington VJ. Technetium and combined gallium and technetium scans in the neutrophic foot. J Amer Podiatr Assoc 1982;72:458–463.Google Scholar
  45. 45.
    Morrison WB, Schweitzer ME, Wapner KL, Hecht PJ, Gannon FH, Behm WR. Osteomyelitis in feet of diabetics: clinical accuracy, surgical utility, and cost-effectiveness of MR imaging. Radiology 1995;196:557–564.PubMedGoogle Scholar
  46. 46.
    Yuh WTC, Corson JD, Baraniewski HM, Rezai K, Shamma AR, Kathol MH, Sato Y, El-khoury GY, Hawes DR, Platz CE, Cooper RR, Corry RJ. Osteomyelitis of the foot in diabetic patients: evaluation with plain film, Tc-MDP bone scintigraphy, and MR imaging. Am J Roentgen 1989;152:795–800.Google Scholar
  47. 47.
    Jones EW, Edwards R, Finch R, Jeffcoate WJ. A microbiologie study of diabetic foot lesions. Diab Med 1984;2:213–215.CrossRefGoogle Scholar
  48. 48.
    Lipsky BA, Pecoraro RE, Wheat LJ. The diabetic foot: soft tissue and bone infection. Infect Dis Clin North Am 1990;4:409–432.PubMedGoogle Scholar
  49. 49.
    Ulbrecht JS, Perry J, Hewitt FG, Cavanagh PR. Controversies in footwear for the diabetic foot at risk. In: Kominsky SJ, ed. Medical and Surgical Management of the Diabetic Foot. Mosby-Year Book, Boston, 1994, pp. 441–451.Google Scholar
  50. 50.
    Attinger CE. Use of soft tissue techniques for the salvage of the diabetic foot. In: Kominsky SJ, ed. Medical and Surgical Management of the Diabetic Foot. Mosby-Year Book, Boston, 1994, pp. 323–366.Google Scholar
  51. 51.
    Gibbons GW, Marcaccio EJ Jr, Burgess AM, et al. Improved quality of diabetic foot care, 1984 vs 1990: reduced length of stay and costs, insufficient reimbursement. Arch Surg 1993;128:576–581.PubMedCrossRefGoogle Scholar
  52. 52.
    Edmonds M, Foster A, Greenhill M, Sinha J, Philpott-Howard J, Salisbury J. Acute septic vasculitis not diabetic microangiopathy leads to digital necrosis in the neuropathic foot. Diab Med 1992;9(Suppl 1):P85.Google Scholar
  53. 53.
    Klamer TW, Towne JB, Bandyk DF, Bonner MJ. The influence of sepsis and ischemia on the natural history of the diabetic foot. Am Surg 1987;53:490–494.PubMedGoogle Scholar
  54. 54.
    Pomposelli FB Jr, Jepsen SJ, Gibbons GW, et al. A flexible approach to infrapopliteal vein grafts in patients with diabetes mellitus. Arch Surg 1991;126:724–729.PubMedCrossRefGoogle Scholar
  55. 55.
    Pomposelli FB Jr, Jepsen SJ, Gibbons GW, et al. Efficacy of the dorsalis pedis bypass for limb salvage in diabetic patients: short term observations. J Vasc Surg 1990;11:745–752.PubMedGoogle Scholar
  56. 56.
    Goldenberg SG, Allen M, Joshi RA, Blumenthal HT. Nonatheromatous peripheral vascular disease of the lower extremity in diabetes mellitus. Diabetes 1959;8:261–273.PubMedGoogle Scholar
  57. 57.
    LoGerfo FW, Coffman JD: Vascular and microvascular disease in the diabetic foot: implications for foot care. N Engl J Med 1984;311:1615–1619.PubMedCrossRefGoogle Scholar
  58. 58.
    Golner MG. The fate of the second leg in the diabetic amputee. Diabetes 1960;9:100–103.Google Scholar
  59. 59.
    Chang BB, Bock DE, Jacobs RL, Darling RC, Leather RP, Shah DM. Increased limb salvage by the use of unconventional foot amputations. J Vasc Surg 1994;19:341–349.PubMedCrossRefGoogle Scholar
  60. 60.
    Armstrong DG, Lavery LA, Stern S, Harkless LB. Is prophylactic diabetic foot surgery dangerous?: J Foot Ankle Surg 1996;35:585–589.PubMedCrossRefGoogle Scholar
  61. 61.
    Rosenblum BI, Pomposelli FB, Giurini JM. Maximizing foot salvage by a combined approach to foot ischemia and neuropathic ulceration in patients with diabetes mellitus: a five year experience. Diabetes Care 1994;17:983–987.PubMedCrossRefGoogle Scholar
  62. 62.
    Martin JD, Delbridge L, Reeve TS, Clagett GP. Radical treatment of mal perforans in diabetic patients with arterial insufficiency. J Vasc Surg 1990;12:264–268.PubMedGoogle Scholar
  63. 63.
    Frykberg R, Giurini J, Habershaw G, Rosenblum B, Chrzan J. Prophylactic surgery in the diabetic foot. In: Kominsky SJ, ed. Medical and Surgical Management of the Diabetic Foot. Mosby-Year Book, Boston, 1994.Google Scholar
  64. 64.
    Sanders LJ, Frykberg RG. Diabetic neuropathic osteoarthropathy: the Charcot foot. In: Frykberg RG, ed. The High Risk Foot in Diabetes Mellitus. Churchill Livingstone, New York, 1991, pp. 297–338.Google Scholar
  65. 65.
    Sinha S, Munichoodappa C, Kozak GP. Neuroarthropathy (Charcot joints) in diabetes mellitus: clinical study of 101 cases. Medicine 1972;52:191–210.CrossRefGoogle Scholar
  66. 66.
    Lesko P, Maurer PC. Talonavicular dislocations and midfoot arthropathy in neuropathic diabetic feet: natural course and principles of treatment. Clin Orthop 1989;240:226.PubMedGoogle Scholar
  67. 67.
    Bier RR, Estersohn HS. A new treatment for Charcot joint in the diabetic foot. JAPMA 1987;77:63–69.Google Scholar
  68. 68.
    Janisse DJ. Prescription insoles and footwear. Clin Podiatr Med Surg 1995;12:41–61.PubMedGoogle Scholar
  69. 69.
    Banks AS, McGlamry ED. Charcot foot. J Am Podiatr Med Assoc 1989;79:213–235.PubMedGoogle Scholar
  70. 70.
    Bono JV, Rogers DJ, Jacobs RL. Surgical arthrodesis of the neuropathic foot: a salvage procedure. Clin Orthop Rel Res 1993;296:14–20.Google Scholar
  71. 71.
    Papa J, Myerson M. Salvage, with arthrodesis, in intractable diabetic neuropathic arthropathy of the foot and ankle. J Bone Joint Surg Am 1993;75:1056–1066.PubMedGoogle Scholar
  72. 72.
    Knighton DR, Fylling CP, Fiegel VD, Cerra F. Amputation prevention in an independently reviewed at-risk diabetic population using a comprehensive wound care protocol. Am J Surg 1990;160:466–472.PubMedCrossRefGoogle Scholar
  73. 73.
    Steed DL, Edington H, Moosa HH, Webster MW. Organization and development of a university multidisciplinary wound care clinic. Surgery 1993;114:775–779.PubMedGoogle Scholar
  74. 74.
    Kozak GP, Rowbotham JL, Gibbons GW. Diabetic foot disease: a major problem. In: Kozak GD, et al., eds. Management of Diabetic Foot Problems. Saunders, Philadelphia, 1995, pp. 1–9.Google Scholar
  75. 75.
    Bennett NT, Schulz GS. Growth factors and wound healing biomechanical properties of growth factors and their receptors. Am J Surg 1993;165:728–737.PubMedCrossRefGoogle Scholar
  76. 76.
    Bennett NT, Schulz GS. Growth factors and wound healing: part II. Role in normal wound and chronic wound healing. Am J Surg 1993;166:74–81.PubMedCrossRefGoogle Scholar
  77. 77.
    Steed DL, Diabetic Ulcer Study Group. Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity diabetic ulcers. J Vasc Surg 1995;21:71–81.PubMedCrossRefGoogle Scholar
  78. 78.
    Boulton AJM, Levin S, Comstock J. A multicentre trial of the aldose reductase inhibitor, tolrestat, in patients with symptomatic diabetic neuropathy. Diabetologia 1990;33:431.PubMedCrossRefGoogle Scholar
  79. 79.
    Sima AAF, Brill V, Nathaniel T, et al. Regeneration and repair of myelinated fibres in sural nerve biopsy specimens from patients with diabetic neuropathy treated with sorbinil. N Engl J Med 1988;319:548.PubMedCrossRefGoogle Scholar
  80. 80.
    Keen H, Payan J, Allawi J, et al. Treatment of diabetic neuropathy with γ-linolenic acid. Diabetes Care 1992;16:8.CrossRefGoogle Scholar
  81. 81.
    Young RJ, Clarke BF. Pain relief in diabetic neuropathy: the effectiveness of imipramine and related drugs. Diabetes Med 1985;2:262.CrossRefGoogle Scholar
  82. 82.
    Selby PL, Young MJ, Boulton AJM. Bisphosphonates: a new treatment for diabetic Charcot neuroarthropathy? Diabetes Med 1994;11:28–31.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 1998

Authors and Affiliations

  • John M. Giurini
  • Barry I. Rosenblum
  • Thomas E. Lyons

There are no affiliations available

Personalised recommendations