Foot & Ankle Ulcers / Wounds

​Overview
Foot and ankle wounds are breaks in the skin and underlying tissue that fail to heal normally due to impaired circulation, nerve damage, pressure, or systemic disease.
They are common in patients with diabetes mellitus, peripheral vascular disease, or venous insufficiency and represent a major cause of infection, hospitalization, and amputation worldwide.
Early recognition, accurate classification, and appropriate treatment are essential to prevent complications such as osteomyelitis and limb loss.


Types of Foot and Ankle Wounds
Foot and ankle wounds are generally classified by underlying etiology into three major categories:

1. Arterial (Ischemic) Ulcers
2. Venous (Stasis) Ulcers
3. Neuropathic (Diabetic) Ulcers

A single patient may have mixed-etiology wounds, particularly in the setting of diabetes or advanced peripheral vascular disease.


1. Arterial (Ischemic) Ulcers
Etiology
Arterial ulcers result from reduced blood flow to the lower extremity due to peripheral arterial disease (PAD) or arteriosclerosis obliterans.
Tissue ischemia leads to necrosis and ulceration, most often in distal sites with poor perfusion.
Risk factors:

• Diabetes mellitus
• Smoking
• Hypertension
• Hyperlipidemia
• Advanced age
• Chronic kidney disease

Clinical Features

• Location: Toes, lateral malleolus, anterior shin, or pressure points.
• Appearance: Punched-out edges, pale wound base, minimal exudate.
• Surrounding skin: Thin, shiny, hairless.
• Pain: Often severe, especially at night or when legs are elevated.
• Pulses: Diminished or absent.
• Capillary refill: Delayed.

Treatment

• Restore perfusion: Referral to vascular surgery for evaluation; endovascular angioplasty or bypass as indicated.
• Local wound care: Gentle debridement, moisture balance, and infection control.
• Avoid compression therapy (contraindicated in severe ischemia).
• Optimize systemic factors: Smoking cessation, control of blood pressure, diabetes, and cholesterol.
• Antiplatelet and vasodilator therapy as indicated.

Expectations
Healing depends on revascularization. Without improved blood flow, these wounds rarely heal and carry a high risk of amputation. With successful revascularization and optimal wound care, many can achieve closure within 3–6 months.


2. Venous (Stasis) Ulcers
Etiology
Venous ulcers are caused by chronic venous hypertension due to venous valve incompetence or post-thrombotic syndrome.
Elevated venous pressure leads to capillary leakage, tissue edema, and skin breakdown.
Risk factors:

• History of deep vein thrombosis (DVT)
• Varicose veins
• Obesity
• Prolonged standing or immobility

Clinical Features

• Location: Medial malleolus or lower leg above the ankle.
• Appearance: Irregular borders, shallow wound, moderate to heavy exudate.
• Surrounding skin: Hemosiderin staining, lipodermatosclerosis, edema, dermatitis.
• Pain: Mild to moderate, relieved by leg elevation.
• Pulses: Usually present.

Treatment

• Compression therapy: Mainstay of treatment (multilayer wraps, stockings, Unna boot).
• Elevation of legs above heart level.
• Wound care: Absorptive dressings for exudate, gentle debridement if needed.
• Address infection or dermatitis.
• Venous surgery or ablation: Consider for recurrent or refractory ulcers.
• Exercise and calf-muscle strengthening to enhance venous return.

Expectations
With proper compression and wound care, most venous ulcers heal within 3–6 months.
Recurrence is common (20–70% within 5 years) without ongoing compression and lifestyle modification.


3. Neuropathic (Diabetic) Ulcers
Etiology
Neuropathic ulcers occur from loss of protective sensation, motor imbalance, and autonomic dysfunction secondary to diabetic neuropathy.
Repetitive trauma on insensate pressure points causes skin breakdown, often compounded by poor circulation and infection.
Risk factors:

• Long-standing diabetes
• Peripheral neuropathy
• Foot deformities (hammer toes, Charcot foot)
• Poor footwear
• Peripheral arterial disease

Clinical Features

• Location: Plantar surface (metatarsal heads, great toe, heel).
• Appearance: Painless, deep ulcer with callused margins; surrounding skin often dry or cracked.
• Pulses: May be present (unless PAD coexists).
• Frequently complicated by infection or osteomyelitis.

Treatment

• Off-loading: Total contact cast (TCC), removable cast walker, or custom orthoses.
• Debridement: Removal of necrotic tissue and callus to promote healing.
• Infection control: Culture-guided antibiotics for cellulitis or osteomyelitis.
• Optimize metabolic factors: Strict glycemic control, smoking cessation, nutrition.
• Wound dressings: Maintain moist, clean wound bed; advanced modalities (negative pressure, bioengineered skin) for complex cases.
• Revascularization: If ischemia is present.
• Patient education: Daily foot checks, appropriate footwear, lifelong surveillance.

Expectations
With comprehensive management, many neuropathic ulcers heal within 3–6 months.
Recurrence rates remain high (30–40%) unless biomechanical and glycemic factors are corrected.
Untreated ulcers can progress to infection, Charcot arthropathy, or amputation.


Multidisciplinary Approach
Effective management often requires a team-based approach, including:

• Podiatry and wound care specialists
• Vascular and orthopedic surgeons
• Endocrinologists or diabetologists
• Nutritionists and rehabilitation therapists

Adjunctive treatments such as negative pressure wound therapy, growth factors, and hyperbaric oxygen therapy may benefit selected cases, particularly chronic or nonhealing wounds.


Key References (Peer-Reviewed)

1. Edmonds M, Foster A. The use of antibiotics in the diabetic foot. Am J Surg. 2004;187(5A):25S–28S.
2. Hinchliffe RJ, Brownrigg JR, Apelqvist J, et al. IWGDF guidance on the diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers in diabetes. Diabetes Metab Res Rev. 2016;32(Suppl 1):37–44.
3. O’Meara S, Cullum N, Nelson EA. Compression for venous leg ulcers. Cochrane Database Syst Rev. 2012;(11):CD000265.
4. Armstrong DG, Boulton AJ, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376(24):2367–2375.
5. Game FL, Jeffcoate WJ. The role of neuropathy in the development of diabetic foot lesions. Diabet Med. 2012;29(12):1456–1462.
6. Fife CE, Carter MJ, Walker D, Thomson B. Wound care outcomes and associated cost among patients treated in U.S. outpatient wound centers: data from the U.S. Wound Registry. Wound Repair Regen. 2012;20(6):767–777.
7. Frykberg RG, Zgonis T, Armstrong DG, et al. Diabetic foot disorders: a clinical practice guideline. J Foot Ankle Surg. 2006;45(5 Suppl):S1–S66.

Summary
Foot and ankle wounds result from arterial insufficiency, venous hypertension, or neuropathic injury, often in combination.
Early recognition and accurate classification are key to effective treatment.

• Arterial wounds require revascularization and protection from trauma.
• Venous ulcers respond best to compression therapy and elevation.
• Neuropathic ulcers require off-loading, debridement, and infection control.

A multidisciplinary, patient-centered approach focused on circulation, pressure relief, and infection prevention offers the best chance for healing and limb preservation.