A diabetic foot ulcer is an open wound that forms on the foot due to diabetes-related complications such as nerve damage (neuropathy), poor circulation (ischemia), and foot deformities. Because diabetes reduces sensation and healing ability, even small injuries can progress into serious ulcers. These wounds often go unnoticed due to numbness and can easily become infected if not treated promptly. Diabetic foot ulcers are one of the most common causes of hospitalization and amputation in people with diabetes.
How Common It Is and Who Gets It? (Epidemiology)
Foot ulcers affect approximately 15–25% of people with diabetes during their lifetime. They are more common in patients who have had diabetes for many years, especially those with neuropathy, peripheral vascular disease, or poorly controlled blood sugar. Older adults, smokers, and people with kidney or heart disease are also at higher risk.
Why It Happens – Causes (Etiology and Pathophysiology)
Diabetic foot ulcers result from a combination of three main factors:
- Sensory neuropathy: Nerve damage reduces the ability to feel pain, pressure, or injury, allowing unnoticed trauma to worsen.
- Motor neuropathy: Weakness or imbalance in foot muscles causes deformities such as hammertoes or bunions, which create high-pressure areas.
- Ischemia (poor circulation): Reduced blood flow delays healing and increases the risk of infection.
Additional contributors include high blood sugar levels, improper footwear, and repeated friction or pressure on weight-bearing areas.
How the Body Part Normally Works? (Relevant Anatomy)
The foot has a complex structure of bones, joints, muscles, and blood vessels that distribute pressure and maintain balance during walking. In healthy individuals, sensation and circulation protect against injury. In diabetes, nerve damage and poor blood supply make the metatarsal heads, heels, and toes particularly prone to breakdown, as these areas bear the most pressure during movement.
What You Might Feel – Symptoms (Clinical Presentation)
Most diabetic ulcers are painless due to neuropathy. Symptoms include:
- An open sore, usually on the sole, heel, or tip of the toes
- Thickened skin or callus around the wound
- Drainage, odor, or discoloration if infected
- Swelling, redness, or warmth
- In advanced cases, blackened tissue (gangrene) indicating dead skin
Some patients only notice a wet spot on their sock or shoe before seeing the ulcer itself.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis involves a physical exam and imaging studies to assess the depth and severity of the ulcer.
- Clinical exam: Inspection for size, depth, drainage, and infection. Pulses and sensation are evaluated.
- X-rays: Identify gas, bone involvement, or deformity.
- MRI: Detects early bone infection (osteomyelitis) or abscesses.
- Wound cultures: Guide antibiotic therapy if infection is present.
- Vascular testing: Checks blood flow to the leg and foot.
Classification
The Wagner Classification System is widely used to grade diabetic ulcers:
- Grade 0: No open wound but high risk (callus, deformity).
- Grade 1: Superficial ulcer without infection.
- Grade 2: Deep ulcer reaching tendon or bone.
- Grade 3: Deep ulcer with abscess or bone infection.
- Grade 4: Partial gangrene of the forefoot.
- Grade 5: Whole foot gangrene requiring amputation.
Other Problems That Can Feel Similar (Differential Diagnosis)
- Arterial or venous ulcers (from vascular disease)
- Pressure sores (bedsores)
- Traumatic or surgical wounds
- Skin cancer or chronic infection
A specialist can distinguish these conditions through examination and imaging.
Treatment Options
Non-Surgical Care
Most diabetic ulcers can heal with proper wound management and offloading.
- Blood sugar control: Maintaining target glucose levels is crucial for healing.
- Debridement: Removal of dead or infected tissue by a trained clinician (never at home).
- Wound cleaning: Daily cleansing with sterile solution and application of appropriate dressings.
- Offloading: Reducing pressure using total contact casts, special diabetic shoes, or braces.
- Dressings: Moist wound dressings, medicated pads, or skin substitutes to promote healing.
- Infection management: Antibiotics are prescribed if the wound shows signs of infection.
- Hyperbaric oxygen therapy: Used in selected cases to improve oxygen delivery and healing.
Surgical Care
Surgery is indicated for ulcers complicated by deep infection, bone involvement, or poor healing.
- Incision and drainage: Removes pus or abscesses.
- Bone resection: Removal of infected bone (osteomyelitis).
- Exostectomy: Removal of bone prominences that cause pressure ulcers.
- Amputation: Performed only when tissue is nonviable or infection cannot be controlled.
Recovery and What to Expect After Treatment
Recovery depends on ulcer severity, infection control, and blood flow:
- Mild ulcers: Heal in weeks with proper care and offloading.
- Deep or infected ulcers: May take months and require hospitalization.
- After surgery: Wound healing continues under close supervision with daily dressing changes and glucose management.
Preventing recurrence through protective footwear and regular foot checks is key.
Possible Risks or Side Effects (Complications)
- Osteomyelitis (bone infection)
- Gangrene and tissue necrosis
- Amputation in severe or untreated cases
- Recurrent ulcers at the same or nearby sites
- Delayed healing due to poor circulation or uncontrolled diabetes.
Long-Term Outlook (Prognosis)
With timely diagnosis and proper management, most diabetic ulcers heal successfully. However, recurrence is common if preventive measures are not followed. Patients with good blood sugar control and healthy circulation have the best outcomes. Untreated ulcers can progress to infection, amputation, and systemic illness.
Out-of-Pocket Costs for Diabetic Foot Ulcer Care
Medicare
CPT Code 28003 – Incision and Drainage (Abscess): $84.89
CPT Code 28122 – Bone Resection (Osteomyelitis): $135.39
CPT Code 28124 – Exostectomy (Pressure Ulcer Relief): $109.01
CPT Code 28820 – Amputation (Nonviable or Infected Tissue): $67.24
Medicare Part B typically covers 80% of the approved costs for these procedures once your annual deductible is met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield generally pay this remaining balance, resulting in little to no out-of-pocket expense for patients undergoing Medicare-approved treatments. These supplemental plans are specifically designed to coordinate with Medicare and reduce your financial responsibility.
If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it serves as a secondary payer after Medicare. These plans often cover any remaining coinsurance or small deductibles, which typically range between $100 and $300 depending on your plan details and network status.
Workers’ Compensation
If your diabetic foot ulcer or resulting infection developed due to a work-related injury, Workers’ Compensation will pay for all related treatments, including incision, drainage, bone resection, and wound care. You will not have any out-of-pocket expenses, as the employer’s insurance carrier will cover all approved costs directly.
No-Fault Insurance
If your diabetic foot ulcer or related complication occurred as a result of an automobile accident, No-Fault Insurance will generally cover the entire cost of medical treatment, including surgery and wound care. The only possible expense may be a small deductible or co-payment as specified in your insurance policy.
Example
Michael Rodriguez developed a diabetic foot ulcer that became infected and required incision and drainage (CPT 28003) followed by bone resection for osteomyelitis (CPT 28122). His estimated Medicare out-of-pocket cost was $135.39. Because Michael had supplemental coverage through Blue Cross Blue Shield, the remaining balance was fully covered, leaving him with no out-of-pocket expense for his treatment.
Frequently Asked Questions (FAQ)
Q. What is Charcot Foot?
A. Charcot foot is a serious condition that affects people with diabetes and neuropathy, where nerve damage leads to the inability to feel pain in the feet, resulting in unnoticed injuries and deformities in the foot bones.
Q. How is Charcot Foot treated?
A. Treatment for Charcot foot aims to stabilize the foot, reduce pain, and make it possible for patients to walk. Treatment methods include bone removal (exostectomy), tendon balancing, reconstruction using screws and plates, and computer-assisted correction for precise adjustments.
Q. What are the risks and benefits of Charcot Foot surgery?
A. Risks include infection and poor bone healing, while the benefits include healing ulcers, returning the foot to a normal shape, and preventing amputation. Studies show that only about 5.5% of patients require amputation after surgery.
Q. What is the recovery time after Charcot Foot surgery?
A. Recovery can take several months, with most patients able to walk again after surgery. Full recovery and the ability to engage in normal activities depend on rehabilitation and follow-up care.
Q. What are the causes of Charcot Foot?
A. Charcot foot occurs when nerve damage, often from diabetes, leads to an inability to feel pain or discomfort, which allows minor foot injuries to go unnoticed and result in joint and bone deformities.
Q. How can Charcot Foot lead to amputation?
A. If untreated, the deformities and ulcers caused by Charcot foot can become severe, increasing the risk of infection and requiring amputation of part of the foot or leg.
Q. Can Charcot Foot be prevented?
A. While Charcot foot can be difficult to prevent, managing diabetes effectively, regular foot care, and addressing injuries early can help reduce the risk of developing the condition.
Q. What are the symptoms of Charcot Foot?
A. Symptoms include swelling, redness, warmth, and a collapsed arch in the foot, often accompanied by pain or deformity. However, many patients experience little to no pain due to nerve damage.
Q. How is Charcot Foot diagnosed?
A. Diagnosis is made through a combination of clinical evaluation, imaging studies like X-rays, MRI, or CT scans, and sometimes bone scans to assess the degree of bone damage and deformity.
Q. Can Charcot Foot occur in people without diabetes?
A. Yes, while Charcot foot is most common in diabetic patients, it can also occur in individuals with other conditions that lead to nerve damage, such as spinal cord injuries or peripheral neuropathy.
Q. Is surgery always necessary for Charcot Foot?
A. Surgery is not always required but may be necessary for severe deformities or when conservative treatments like immobilization and custom footwear do not alleviate symptoms or prevent further complications.
Q. What are conservative treatments for Charcot Foot?
A. Conservative treatments include rest, immobilization with a cast or brace, and wearing custom shoes or orthotics to stabilize the foot and prevent further damage while allowing the bones to heal.
Q. Can Charcot Foot be treated without surgery?
A. In the early stages, Charcot foot can often be managed without surgery through proper offloading, custom footwear, and close monitoring. Surgery may be required for advanced cases or when conservative measures fail.
Q. How does Charcot Foot affect mobility?
A. Charcot foot can significantly impact mobility if not treated, causing deformities that lead to difficulty walking, imbalanced gait, and increased risk of further foot injuries or ulcers. Early intervention can help maintain mobility.
Q. What causes diabetic foot ulcers?
A. They result from nerve damage, poor circulation, and pressure points on the foot.
Q. Are diabetic foot ulcers painful?
A. Usually not, because nerve damage reduces sensation.
Q. How are ulcers treated?
A. Treatment includes wound cleaning, pressure offloading, antibiotics for infection, and strict glucose control.
Q. Can diabetic ulcers heal completely?
A. Yes, with early and proper treatment, most ulcers heal fully.
Q. When is surgery necessary?
A. Surgery is needed for infected, deep, or non-healing ulcers.
Q. Can diabetic ulcers lead to amputation?
A. Yes, untreated ulcers can cause severe infection and tissue death, which may require amputation.
Summary and Takeaway
Diabetic foot ulcers are serious but preventable complications of diabetes caused by neuropathy, poor circulation, and foot deformities. Early recognition, daily foot care, proper footwear, and blood sugar control can prevent ulcers and reduce the risk of infection and amputation. Prompt medical attention and multidisciplinary care are essential for healing and long-term limb preservation.
Clinical Insight & Recent Findings
Charcot neuropathic osteoarthropathy (Charcot foot) remains a serious and often underdiagnosed complication of diabetes-related neuropathy. A recent review highlights that the condition stems from unperceived microtrauma and abnormal inflammatory responses, leading to bone destruction, deformity, and ulcer risk.
Early recognition—often missed due to misdiagnosis as cellulitis or osteomyelitis—is critical, with modern imaging (MRI, nuclear scans) improving accuracy. Treatment relies first on immobilization and offloading with total contact casting or custom orthoses; surgery is reserved for severe or unstable deformities. Newer surgical methods, such as internal/external fixation and 3D-printed implants, have improved limb salvage, with success rates approaching 95% in specialized centers.
Despite advances, up to one quarter of patients still experience mobility loss, and long-term mortality remains high. Early diagnosis, optimal diabetes control, and multidisciplinary care are key to improving outcomes. (“Study on new approaches to Charcot foot care – see PubMed“)
Who Performs This Treatment? (Specialists and Team Involved)
Diabetic foot ulcers are managed by podiatrists, orthopedic foot and ankle surgeons, vascular surgeons, wound care specialists, and infectious disease physicians. Nurses and physical therapists assist with daily dressing changes and rehabilitation.
When to See a Specialist?
You should see a specialist if you notice any foot sores, redness, swelling, or drainage, especially if you have diabetes or reduced sensation in your feet.
When to Go to the Emergency Room?
Seek immediate medical attention if:
- The ulcer is deep or bleeding heavily
- You have fever, redness, or pus indicating infection
- The skin turns black or foul-smelling (signs of gangrene).
What Recovery Really Looks Like?
Healing requires consistent care: daily wound cleaning, offloading, and blood sugar monitoring. Patients often wear special shoes or casts to protect the foot during recovery. Full healing can take several weeks to months.
What Happens If You Ignore It?
Untreated diabetic ulcers can lead to infection, bone damage, and amputation. They may also worsen other diabetic complications such as vascular disease or kidney failure.
How to Prevent It?
- Inspect your feet daily for blisters, redness, or sores
- Keep blood sugar, cholesterol, and blood pressure under control
- Wear properly fitting, breathable shoes
- Avoid walking barefoot
- Visit a podiatrist regularly for nail and skin care.
Nutrition and Bone or Joint Health
A balanced diet rich in lean proteins, vitamin C, zinc, and omega-3 fatty acids supports tissue repair. Maintaining proper hydration and glucose control also enhances wound healing.
Activity and Lifestyle Modifications
Avoid standing or walking for prolonged periods on healing ulcers. After recovery, wear diabetic shoes or orthotic inserts to reduce pressure points and prevent recurrence.
Dr. Mo Athar
