When taking care of any person with an impairment in skin integrity, a comprehensive assessment of both the wound and the patient must occur simultaneously. It can be important to assess the “unwounded” limb as well.

Let’s review some common characteristics of neuropathic wounds, remembering that while the majority of these wounds are due to peripheral neuropathy, some patients have angiopathy or an ischemic component to their wounds.

Location: Neuropathic ulcers are located on the plantar or walking surface of the foot. 71% of ulcers occur on the forefoot , and the 3rd metatarsal head is most affected followed by the great toe, and the 1st and 5th metatarsal head. Ischemic wounds, on the other hand, are usually found on the lateral side of the foot, over the malleolus and toes, or on the heel. Wounds found on the dorsum (or top) of the foot are usually due to trauma.

Size and shape: Neuropathic ulcers tend to be small and have a round, punched-out (punctate) appearance. Depth may range from partial thickness or may probe to bone, which is a significant indicator of the presence of osteomyelitis. Ulcers may present with or without sinus tracts, tunneling or undermining.

Grade: While we use a staging system with pressure ulcers to indicate the depth of tissue damage, a grading system is used for neuropathic foot ulcers to facilitate a common language. The Wagner Ulcer Grade Classification grades ulcers from 0-5 and provides descriptors for each grade, ranging from 0--intact skin, preulcer lesion, healed ulcer, presence of bony deformity, to 5--gangrene of the foot requiring disarticulation. The University of Texas classification system offers both a stage (A-D) and grade (0-3) for each wound and addresses infection and ischemia in their schemata.

Wound Bed or base of wound is usually red, unless there is an ischemic component to their disease.

Wound edges or margins: usually even and well defined. Often with neuropathic ulcers there will be an area of callous which forms around the wound edges.

Exudate can vary in quantity and quality, from small to moderate amounts, serous in quality. Purulent, thick exudate may indicate infection.

Periwound skin or surrounding skin: Observe and palpate the surrounding skin and feet noting any warmth, swelling or induration which may indicate that an infection is brewing. Note character of skin and any callus formation surrounding the ulcer indicating that pressure is not being relieved in that area.

Pain: It is not surprising that these ulcers are usually painless due to the fact that the patient has neuropathy and has lost sensation in that area. Anytime a patient who has previously had an insensate foot starts to complain of pain, the caregiver should get an immediate and urgent referral to a specialist in order to prevent limb loss.

Offloading the Diabetic Foot

Selection of appropriate footwear needs to occur before ulceration or amputation. The use of lambs wool between toes, padded socks, inserts and crest pads for hammer or claw toes can be beneficial in providing pressure relief. The presence of a diabetic foot wound demands offloading the foot 24/7 to relieve pressure and strain to the affected area. In essence, the patient needs to be non-weight bearing in order for the wound to close. The total contact cast is especially useful in this regard and has been referred to as the gold standard of treatment of non-infected neuropathic ulcers. Pressures are totally redistributed away from the ulcer and the patient is “forced” into compliance due to the nature of the cast. A non-randomized study of 1350 diabetic foot ulcer patients demonstrated 88% ulcer closure in 5 weeks using the total contact cast, 63% with the 3-D walker with custom insoles, and 55% closure with custom sandals with three layers of foam (Hanft, 2000). There is little evidence that assistive devices facilitate wound healing.