This weeks “Foundations” article looks at the causal pathways for development of lower extremity ulcerations in  patients with diabetes.  By understanding the causal pathways that lead to diabetic foot ulcerations we can use proven strategies to prevent and decrease the impact, particularly of these modifiable conditions that lead to diabetic foot ulcerations.

This particular trial was performed in 3 sites in both the US and the UK.  Demographics among the sites was not felt to be statistically significant.  Three significant components were present in the majority of the pathways that led to foot ulcerations those being peripheral neuropathy, minor trauma and foot deformity.  Of all of the factors identified peripheral neuropathy was the most common present is 78% of the ulcer pathways.  Structural deformities of the foot were also common, and felt to be associated with the underlying neuropathy. Identified changes included: claw toe, hammertoe, distal migration of the plantar fat pad and flattening of the longitudinal arches.  Minor trauma was also an important component finding that particular factor in 77% of all pathways leading to ulceration.  Less commonly identified features such as edema, lower limb ischemia and callus/ hyperkeratoses were found in the causal pathway to rate of 37%, 35%, and 30% respectively.

The implications of the data presented by this study show that detection of clinically significant loss of protective sensation and counseling on good glycemic control can help decrease the progression towards worsening neuropathy.  Relatively minor trauma, as simple as shoe – related minor trauma, in the insensate foot can lead to formation of ulceration and is at target for prevention.  Proper selection of foot wear to relieve plantar pressure, formation of callus and accommodate and support foot deformities should be a goal.

Reiber,G et. al.: Causal Pathways for Incident Lower-Extremity Ulcers in Patients with Diabetes from Two Settings. Diabetes Care, Vol 22:157-162, Jan 1999