Robert J. Hinchliffe, MD, MRCS, Clinical Lecturer in Vascular Surgery, St George’s Regional Vascular Institute, St George’s Hospital and St George’s University of London, London, UK.
William Jeffcoate, FRCP, Professor, Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University Hospitals, City Hospital Campus, Nottingham, UK.

Individuals with ulceration of the foot should be identified and referred urgently to a specialist. Unfortunately there is little formal health care education in diabetic foot ulceration and often no specialist referral pathway. We discuss the common modes of presentation of patients with diabetes and foot ulcer. The clinical implications of a range of symptoms and signs will be explained, including the most common diagnostic pitfalls in everyday primary care practice.
Key words: diabetes, peripheral vascular disease, ulcer, vascular surgery, peripheral arterial disease, diabetic foot.

Naven Duggal, MD, FRCSC, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.

Diabetes mellitus is a major cause of nontraumatic lower extremity amputation in Canada and the United States. This multisystemic disease is most effectively managed by a team approach. Structural abnormalities and the resultant plantar ulcers will increase the risk of amputation among older adults with diabetes. Effective management of the diabetic foot begins with education and prevention.
Key words: diabetic foot, amputation, diabetic ulcers, Charcot arthropathy.

Timothy Daniels, MD, FRCSC, Associate Professor, University of Toronto, Toronto, ON.
Eran Tamir, MD, Department of Orthopaedic Rehabilitation, Sheba Medical Center, Tel-Hashomer, Israel.

Neuropathic foot complications are increasing in frequency, and surgery is becoming recognized as an important adjunct to their treatment and prevention.
The development of a diabetic foot ulcer is a multifactorial process; however, the presences of obvious and/or subtle foot deformities are being recognized as a significant contributing factor.
Off-loading of the affected area is the standard of care and commonly results in healing the noninfected neuropathic ulcer. Methods of off-loading can be broadly categorized as external (nonweightbearing, casting, braces, orthotics, and shoes) or internal (surgical intervention to correct the deformity).
Reconstructive surgery can prevent foot complications when conservative methods fail. By correcting the musculoskeletal deformity, the areas at risk are off-loaded so that the prevention of ulcer becomes less dependent on protective footwear and patient compliance.
Key words: Diabetic foot, ulceration, off-loading, surgery, reconstruction.

Oksana Davidovich, BSc, DCh (Chiropodist), Private Practice: Davisville Foot Clinic; President of the Ontario Society of Chiropodists, Toronto, ON.

Diabetic neuropathic foot ulcers, often a precursor to amputation, occur in high-pressure areas on the sole of the foot. Ulcer healing can be achieved through a combination of wound management and a variety of offloading modalities. Total contact casts and removable cast walkers are effective methods for facilitating wound closure. Alternatively, a wide range of temporary, weight-relief shoes and healing sandals are also effective in resolving active ulcers. Once the wound has healed, prevention strategies typically include custom-made, modified, or premade orthopedic shoes used in conjunction with foot orthoses, as well as a regular podiatric examination to screen for potential complications.

Key words: diabetic foot, foot ulcer, cast, orthopedic footwear, foot orthoses.

Leslie Goldenberg, BSc, MD, FRCPC
Internal, Geriatric and Podologic Medicine
Assistant Professor of Medicine, University of Toronto
Medical Director, The Walking Mobility Clinics 

The first principle in the care of the diabetic foot is to recognize the primacy of prophylactic care. Indeed, an ounce of prevention is worth the proverbial pound of cure, even in the patient who appears to be low risk and does not suffer from peripheral neuropathy or vasculopathy. Physicians and other health care professionals have a critically important role to play when it comes to educating their diabetic patients regarding daily foot care, with particular attention paid to the care of skin, nail and callus, proper footwear and strategies to prevent foot trauma and infection. Diabetes remains the most common cause of non-traumatic limb loss, and there is considerable suffering and economic impact associated with the management of chronic diabetic foot pain and sepsis. Two-thirds of diabetic amputations follow complications that are related to foot ulcers.

Pressure platform studies demonstrate that the patient placing a diminished load on the toes is an early finding in diabetic neuropathy. This reduction in the load on the toes leads to a corresponding increase in metatarsal head loads. In addition, there is a shift of loading on the forefoot, away from the medial side, with increasing load now borne under the mid-foot, a characteristic of weakness of the longitudinal arch (mid-tarsal loading).