Ulceration is an extremely common complication in diabetic patients. Ulcers can occur in up to 12% of the diabetic population. The plantar surface is the most common site of ulceration, especially at areas of bony prominence. Complications related to diabetic ulceration are responsible for up to 85% of lower extremity amputations.

The presence of neuropathy is the key factor in development of diabetic ulceration. Protective sensation is lost and the patient is unaware of the trauma occurring. Autonomic dysfunction also occurs which leads to excessive dryness because of loss of normal glandular secretions. Dry cracked skin is more susceptible to breakdown. Bony prominence secondary to Charcot arthropathy will also increase shear stress in the area. Repetitive trauma produces tissue inflammation which then progresses to tissue necrosis and ulceration.


Presentation may vary dramatically. A patient may present with what they believed to be a simple “blister” that has not resolved. Alternatively the patient may present with florid sepsis secondary to deep soft tissue infection or osteomyelitis.


Wagner Classification

  • Stage 0: Skin intact but with bony prominence – “at risk”
  • Stage 1: Superficial ulcer
  • Stage 2: Full thickness ulcer
  • Stage 3: Deep abscess or osteomyelitis
  • Stage 4: Partial gangrene of forefoot
  • Stage 5: Extensive gangrene

Brodsky Depth – Ischemia Classification Patients are evaluated separately for depth and ischemia, and assigned both a number and letter grade.

  • Depth 0: At risk, no ulcer
  • Depth 1: Superficial ulcer, non-infected
  • Depth 2: Deep ulcer with tendon or joint exposure
  • Depth 3: Extensive ulceration or abscess


  • A: Not ischemic
  • B: Ischemia without gangrene
  • C: Partial forefoot gangrene
  • D: Complete gangrene

Prevention is a primary focus in all patients with diabetes and peripheral neuropathy. Patients with these conditions should be counseled regarding proper foot care. They need to check their feet daily. They should be admonished not to walk barefoot, even indoors. Custom total contact inserts constructed with a closed cell foam such as Plastizote and extra depth shoes are critical. Proper hygiene is also important. Because of autonomic dysfunction that occurs with neuropathy, they should moisturize their feet with a lanolin based ointment.

Treatment of an acute ulcer can vary depending on many factors. The presence of an active infection may require urgent debridement and IV antibiotics. An ulcer without acute infection will usually respond to in-office debridement and offloading. Total contact casting and strict non-weightbearing are commonly used. Frequent debridements in office may be required throughout the healing process. Achilles lengthening or gastrocnemius recession can be useful in minimizing ulcer recurrence. In patients with Charcot arthropathy, ulcers can form under bony prominences secondary to deformity. In these cases, reconstruction with correction of the deformity may be considered. It is also an option to remove the bony prominence creating the ulcer without extensive reconstruction in an otherwise braceable foot. Amputation is also an appropriate treatment option when necessary. Level of amputation depends on location of wound and vascularity.

Written by Brian Kleiber, MD Reviewed by Thomas Dowd, MD Last reviewed June 2015