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General DFU management

Management of the diabetic foot often requires a holistic approach,

which involves a focused multidisciplinary team consisting of a

wound nurse, podiatrist, vascular surgeon, endocrinologist and

other allied healthcare professionals.


However, the overall

wound management of chronic DFUs can last for extended

periods without any healing response, due to the multiple complex

pathophysiological mechanisms involved in patients suffering from

diabetes. These can involve hypoxia, dysfunction in the fibroblasts

and epidermal cells, impaired angiogenesis and neovascularisation,

high levels of metalloproteases, damage from oxygen radicals

and advanced glycation end-products.


Peripheral neuropathy

can also contribute to the development and impaired healing of

DFUs. Neuropeptides such as nerve growth factor, substance P and

calcitonin gene-related peptide, and sensory nerves are needed to

induce wound healing, however their low levels in diabetic patients

have been associated with the development of DFUs.


Despite all these challenges, there is increasing cause for

optimism in the treatment of diabetic ulcers. This is due to the

enhanced understanding and correction of these pathogenic

factors, combined with stricter adherence to standards of care and

technological breakthroughs in biological agents, and this is giving

new hope to the problem of impaired healing of diabetic ulcers.


ulceration but who have foot deformity.


Different off-loading

techniques are commonly used to protect a diabetic foot from

excessive pressure and other forms of trauma that sometimes lead

to diabetic ulceration or even worse, amputation. These can be

grouped into casting, footwear-related and surgical off-loading

techniques, and other.


Off-loading techniques used by podiatrists

in South Africa and overseas include felt padding, prescription

orthotics and insoles, removable cast walkers and total-contact

casting (Figs 2–5).


Key message:

Patients with diabetes mellitus develop foot

problems, such as neuropathy, infections, ulcers and vascular

diseases, which require an integrated multidisciplinary approach

to address all these problems. Failure to adequately treat and

resolve these problems can be due to the multiple complex

pathophysiological mechanisms involved with diabetes, which

is a multisystem disease.

Podiatric DFU management

A podiatrist’s approach to the treatment of DFUs consists of an

overall assessment of the structure and function of the lower limb by

performing biomechanical evaluation, and gait and plantar pressure

analysis. Thus podiatric management and involvement can prevent

diabetic ulcer recurrence in patients through the use of various off-

loading techniques and diabetic patient foot education.


Podiatrists also provide patients with local wound care, which

involves debridement of necrotic tissue and callus, cleansing with

suitable solutions, wound dressings, topical or oral antibiotics when

infection is present, and revascularisation.


This is the general

standard of wound management that is implemented in diabetic

ulcer wound-care clinics and it involves a multidisciplinary team, as

alluded to earlier.

Key message:

Podiatrists are professionals trained to assess

and implement treatment for diabetic lower limb and foot

problems, including diabetic foot ulcers. Podiatrists manage and

treat diabetic foot through wound debridement, appropriate

wound cleansing and dressings, off-loading, infection control

and education.


Off-loading is an essential tool that is used in the healing of DFUs,

particularly in cases where a patient has a plantar neuropathic

ulcer (Fig. 1), or for secondary prevention in patients with healed

Key message:

Off-loading can be defined as a treatment

modality where practitioners try to protect the foot or reduce

excessive pressure that can lead to ulceration or even amputation

in the diabetic foot. Different off-loading techniques can be

implemented with varying results/success, with some techniques

better than others.

Footwear and orthotic devices for the prevention of DFU

Therapeutic footwear in combination with custom-made orthotic

devices (Fig. 2) are considered the primary means of protecting the

foot from excessive plantar pressure during walking, thus reducing

the incidence of ulceration.

In a study by Mueller

et al.

investigating the effect of total-contact

cast inserts (TCIs) and metatarsal pads (MPs) on metatarsal peak

pressures and pressure–time integrals, it was found that the TCI

Fig. 1.

Diabetic neuropathic ulcer.