Diabetic foot problems: Treatment

Photo of the sole of a foot

People with diabetic foot problems may develop chronic wounds (foot ulcers). But these wounds can heal again if treated in time. Amputation can often be avoided in this way.

Treating a chronic wound on the foot takes patience, but it often pays off: The right measures can be very effective. But doctors might still suggest amputation if the wound is large. It is then a good idea to seek further advice and a second medical opinion.

How is diabetic foot treated?

The most important things you can do are:

  • Relieve all pressure on the wounds – this is crucial!
  • Improve blood flow in the leg.
  • Treat wounds, inflammations and infections.
  • Have regular medical check-ups of your feet, even if you don’t think there are any problems.
  • Keep a close eye on your feet and take proper care of them.

Other options include:

  • Medical foot care / advanced podiatry treatment (removal of hard skin, nail care and nail treatment)
  • Better blood sugar regulation
  • Patient education about managing diabetic foot
  • Skin or tissue graft
  • Amputation

How quickly a wound heals due to treatment mainly depends on how big and deep the wound is, where it is, and how consistently pressure is relieved. If there's a blood flow problem, it has to be fixed with surgery. Small wounds can heal within a few weeks. Bigger wounds may take months to heal.

There is a rare kind of diabetic foot known as Charcot foot (neuroarthropathy), which leads to broken bones and deformations. The treatment here involves completely immobilizing the foot (keeping it still) to stabilize it and prevent further bone damage. A plaster cast or a knee-high brace is worn for several months. Special custom orthopedic shoes are worn afterwards to prevent any further damage.

How is pressure kept off the foot?

A wound can only heal properly if it's completely relieved of pressure. Depending on the type of wound, the following options are available:

  • Special shoes (pressure-relieving shoes)
  • Special plaster casts or orthotics (ankle or calf-high braces)
  • Walking aids or a wheelchair
  • Surgery to correct deformities (e.g. hammer toes or claw toes)
  • Removal of calluses (hard, thick skin)

How are wounds treated?

Wound treatment involves:

  • Cleaning the wound: Dead and infected tissue and debris are regularly cleaned out of the wound. That can be done using a scalpel, scissors and wound rinses.
  • Wound dressings: Wound dressings keep the wound moist, absorb wound fluid and prevent from the outside.

Which wound dressing is most suitable depends on things such as how deep the wound is, whether it is infected, and what stage of healing it is at. The dressings have to be changed regularly.

An infected wound can't heal. Severe infections may also spread through the body and become life-threatening. For this reason, it is very important to regularly clean an infected wound thoroughly and take for long enough (often for several weeks). Infected pieces of bone and other tissue can be surgically removed.

A skin graft or tissue graft may speed up the healing of the wound. Skin grafts involve covering the wound with skin taken from another part of your body. A thin layer of skin from the thigh is normally used. It grows onto the wound and can help to close it up. In tissue grafts (flap surgery), the wound is covered with a piece of tissue from your own body (for example, taken from the thigh).

How is blood flow improved?

A lot of people with diabetes have narrow blood vessels. Typical symptoms of blood circulation problems (like pain in the lower legs) easily go unnoticed if people can no longer feel them because of nerve damage. Poor blood flow in the legs prevents the wound from healing properly. Blood flow can be improved with surgery. This can be done in two ways:

  • Vasodilation (PTA = transluminal angioplasty): A tube () is inserted into the groin and pushed through to the narrow artery. A small balloon at the tip of the inflates in the narrow section and widens the artery.
  • Bypass: the blood flow is redirected around the narrow blood vessel. A new vessel (made either of body tissue or synthetic material) is fitted.

These procedures are particularly suitable for people with blood flow problems where wound treatment and relieving pressure wouldn't be enough.

When is amputation considered?

An amputation is only considered if no other treatment options are left. It can often be avoided with good preventive measures and treatment – even if the wound has been there for a long time.

There are different kinds of amputations:

  • Minor amputation: Individual toes or parts of the front of the foot are removed.
  • Major amputation: The whole foot (sometimes with part of the leg) is amputated above the ankle joint.

Amputations may be necessary if

  • a toe or the foot can no longer be saved,
  • a wound can only heal if smaller parts of the foot are removed, or
  • an is spreading through the leg, muscle tissue in the leg is dying, or the pain is too severe.

Doctors only remove as much of the foot as strictly necessary in an amputation. A minor amputation (for instance, removing individual toes) is usually enough. An amputation above the ankle joint is rarely needed.

What is the key to successful treatment?

Ideally, you should go to a diabetes practice that specializes in treating diabetic foot problems as soon as possible. It is also a good idea to have treatment in a specialist foot care center. People living in Germany can find certified centers on the German Diabetes Association’s (DDG) website.

The treatment will be most successful if the various specialists work closely together. These usually include family doctors, diabetologists, podiatrists, vascular medicine (blood vessel) specialists, (foot or cosmetic plastic) surgeons, orthopedic technicians, and nursing staff. It is important that the diabetic foot treatment is coordinated by one doctor’s office. That is usually done by a diabetes center or a diabetic foot outpatient department in a hospital.

Important: Regular check-ups

It is important to have regular foot check-ups. How often you have a check-up depends on how severe the diabetic foot problems are. If you don't have any nerve damage (neuropathy), an annual check-up is enough. If nerves are already damaged, a check-up every six months is recommended. If you have already had a wound, a check-up every one to three months is recommended.

You should also check your feet yourself for sore areas, injuries, redness, fungal infections and any other abnormalities – ideally every day. It can be helpful to use a hand mirror so you can see your whole foot, including the sole and between your toes.

It is important to continue to take good care of your feet even if a wound has healed. Nerve damage doesn't go away, and a new wound can develop at any time.

A second medical opinion can help

It is sometimes a good idea to get a second opinion. You have a legal right to do that before certain planned procedures. A second medical opinion is particularly important if a doctor recommends an amputation. An amputation has a major impact on your life, and there might still be other treatment options.

The most important question is the reason for the amputation: Is there really no other way to save the foot? What are the possible pros and cons of the operation?

Getting a second medical opinion means going to another doctor’s office or hospital for advice from specialists. Our decision aid may help too. It briefly summarizes the main advantages and disadvantages of the different treatment options.

Buggy A, Moore Z. The impact of the multidisciplinary team in the management of individuals with diabetic foot ulcers: a systematic review. J Wound Care 2017; 26(6): 324-339.

Bundesärztekammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF). Nationale Versorgungsleitlinie: Therapie des Typ-2-Diabetes (S3, in Überarbeitung). AWMF-Registernr.: nvl-001g. 2021.

Dorresteijn JA, Kriegsman DM, Assendelft WJ, Valk GD. Patient education for preventing diabetic foot ulceration. Cochrane Database Syst Rev 2014; (12): CD001488.

Elraiyah T, Prutsky G, Domecq JP, Tsapas A, Nabhan M, Frykberg RG et al. A systematic review and meta-analysis of off-loading methods for diabetic foot ulcers. J Vasc Surg 2016; 63(2 Suppl): 59S-68S.

Fernando ME, Seneviratne RM, Tan YM, Lazzarini PA, Sangla KS, Cunningham M et al. Intensive versus conventional glycaemic control for treating diabetic foot ulcers. Cochrane Database Syst Rev 2016; (1): CD010764.

Forsythe RO, Apelqvist J, Boyko EJ, Fitridge R, Hong JP, Katsanos K et al. Effectiveness of revascularisation of the ulcerated foot in patients with diabetes and peripheral artery disease: A systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1: e3279.

Hoogeveen RC, Dorresteijn JA, Kriegsman DM, Valk GD. Complex interventions for preventing diabetic foot ulceration. Cochrane Database Syst Rev 2015; (8): CD007610.

Morbach S, Lobmann R, Eckhard M, Müller E, Reike H, Risse A et al. Diabetic Foot Syndrome. Diabetologe 2020; 16(1): 54-64.

The International Working Group on the Diabetic Foot. IWGDF Guidelines on the prevention and management of diabetic foot disease. 2019.

IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.

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Created on June 28, 2022

Next planned update: 2023

Publisher:

Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

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