Diabetic Ulcer Care

1. Overview

Diabetic foot ulcers (DFUs) represent one of the most serious and debilitating complications of diabetes mellitus, profoundly impacting patient quality of life and imposing significant healthcare burdens. Globally, approximately 15% of all individuals with diabetes will develop a DFU in their lifetime, with recurrence rates as high as 70% within five years. These ulcers are the leading cause of non-traumatic lower extremity amputations, emphasizing the critical need for effective prevention and management strategies.

The etiology of DFUs is multifactorial, primarily driven by a triad of peripheral neuropathy, peripheral artery disease (PAD), and biomechanical stressors. Sensory neuropathy leads to a loss of protective sensation (LOPS), rendering patients unaware of repetitive trauma or sustained pressure. Motor neuropathy contributes to intrinsic foot muscle atrophy and subsequent foot deformities, creating high-pressure areas. Autonomic neuropathy impairs sweat and oil gland function, leading to dry, cracked skin susceptible to breakdown. Concurrently, PAD compromises blood supply, hindering wound healing and increasing infection risk. Poor glycemic control further exacerbates these issues by impairing immune function and cellular repair mechanisms.

Physical therapists play a vital role within the multidisciplinary care team for DFUs, contributing significantly to both prevention and comprehensive rehabilitation. Our expertise in biomechanics, therapeutic exercise, manual therapy, and patient education positions us uniquely to address the underlying physical factors contributing to ulcer formation and to facilitate optimal healing and long-term prevention of recurrence.

2. Functional Anatomy

Understanding the intricate functional anatomy of the foot and ankle is paramount for effective physical therapy intervention in diabetic ulcer care. Diabetes-related changes affect multiple systems, predisposing the foot to ulceration.

Skin and Soft Tissues

• Skin Integrity: The skin serves as the primary protective barrier. In diabetes, skin often becomes dry and inelastic due to autonomic neuropathy affecting sweat and oil glands. This leads to fissures and cracks, creating entry points for bacteria. Impaired microcirculation also compromises the skin's ability to repair itself after injury.
• Subcutaneous Tissues: Loss of protective fat padding, particularly under the metatarsal heads, increases localized pressure and shear forces during ambulation.

Nervous System

• Sensory Neuropathy: Critical for protective sensation. Loss of proprioception, pain, temperature, and pressure perception means minor trauma (e.g., ill-fitting shoes, foreign objects, prolonged pressure) goes unnoticed, leading to progressive tissue damage and ulcer formation.
• Motor Neuropathy: Causes weakness and atrophy of intrinsic foot muscles. This results in biomechanical deformities such as hammer toes, claw toes, and pes cavus (high arch), altering the load distribution across the plantar surface and concentrating pressure on specific areas (e.g., metatarsal heads, toe tips).
• Autonomic Neuropathy: Beyond sudomotor dysfunction (dry skin), it can lead to altered vascular tone, resulting in increased blood flow to the foot (vasodilation), which paradoxically can contribute to Charcot neuro-osteoarthropathy.

Vascular System

• Peripheral Artery Disease (PAD): Macrovascular disease leading to stenosis or occlusion of larger arteries, reducing arterial blood flow to the lower extremities. Impaired perfusion is a critical barrier to wound healing, as it limits oxygen and nutrient delivery and waste product removal. Clinical assessment for PAD (e.g., Ankle-Brachial Index - ABI) is essential.
• Microvascular Disease: Affects smaller arterioles and capillaries, impairing oxygen exchange and nutrient supply at the tissue level, further compromising cellular metabolism and wound repair.

Musculoskeletal System

• Joint Mobility: Glycosylation of collagen and other connective tissues can lead to limited joint mobility (e.g., ankle equinus, hallux limitus). Ankle equinus, in particular, increases forefoot plantar pressures during gait, contributing to ulcer formation under the metatarsal heads.
• Bones: Diabetic osteopathy can weaken bones. Charcot neuro-osteoarthropathy, a progressive destructive arthropathy, leads to bone fragmentation, joint dislocation, and severe foot deformities (e.g., rocker-bottom foot), creating new areas of high pressure and ulcer risk. Osteomyelitis, bone infection, can also complicate DFUs.

Biomechanics

The cumulative effect of these anatomical and physiological changes results in altered foot biomechanics. Abnormal gait patterns, reduced shock absorption, and redistributed plantar pressures create shear forces and areas of intense pressure, particularly under the metatarsal heads, hallux, and heels, making these locations highly susceptible to ulceration.

3. 4 Phases of Rehab

Physical therapy rehabilitation for diabetic ulcers is a progressive, phased approach designed to optimize wound healing, restore function, and prevent recurrence. This framework integrates patient education, therapeutic interventions, and collaborative care.

Phase 1: Acute Management and Offloading (Inflammatory/Proliferative Phase)

Goal: Protect the wound, reduce pressure, manage inflammation, promote initial wound healing, and prevent infection.

• Offloading: This is the cornerstone of DFU management. Removing pressure from the wound site is critical for healing.
• Total Contact Cast (TCC): Considered the gold standard for plantar DFUs due to its ability to evenly distribute pressure, reduce shear forces, and immobilize the foot.
• Removable Cast Walkers (RCW)/Offloading Boots: Offer similar pressure reduction but require patient adherence.
• Custom Orthotics and Therapeutic Footwear: Used for localized offloading, particularly for non-plantar ulcers or as a stepping stone to long-term prevention.
• Crutches, Walkers, Wheelchairs: May be necessary for complete non-weight-bearing in severe cases or non-ambulatory patients.
• Wound Care Adjuncts (within PT scope): While primary wound dressing is typically managed by specialized wound care nurses or physicians, physical therapists can apply modalities to support healing.
• Electrical Stimulation (e-stim): High-voltage pulsed current (HVPC) has demonstrated efficacy in accelerating wound healing by enhancing circulation, reducing edema, stimulating cell migration, and inhibiting bacterial growth.
• Therapeutic Ultrasound: Low-frequency pulsed ultrasound can promote cell proliferation and tissue regeneration.
• Edema Management: Compression therapy (if not contraindicated by severe PAD), elevation, and gentle massage can help manage localized edema.
• Patient Education: Crucial for adherence and early detection.
• Importance of glycemic control and adherence to medication.
• Daily foot inspections for signs of new wounds, redness, swelling, or drainage.
• Avoiding barefoot walking, even indoors.
• Nutrition for wound healing.
• Pain Management: Education on neuropathic pain and strategies for non-pharmacological pain relief (e.g., gentle massage, relaxation techniques).

Phase 2: Restoration of Function and Mobility (Proliferative/Remodeling Phase)

Goal: Improve range of motion (ROM), strength, balance, address biomechanical deficits, and prepare for increased activity once the wound shows significant healing.

• Therapeutic Exercise: Initiated cautiously, progressing as the wound closes and tolerates increased activity.
• Range of Motion Exercises: Gentle active and passive ROM for the ankle and foot (e.g., ankle dorsiflexion stretches to combat equinus, toe extension/flexion) to improve flexibility and reduce pressure points.
• Strengthening Exercises: Intrinsic foot muscle strengthening (e.g., toe curls, towel gathers) to improve arch support and toe mechanics. Calf muscle strengthening (e.g., heel raises) to improve propulsion.
• Balance and Proprioception Training: Essential due to sensory neuropathy. Exercises like single-leg stance, tandem walking, and balance board activities (initially seated or with support) to improve stability and reduce fall risk.
• Gait Training: Analyze and correct compensatory gait patterns.
• Focus on weight distribution, heel-to-toe progression, and reducing abnormal shear forces.
• Use of assistive devices (e.g., cane) if needed to improve stability and offload specific areas.
• Manual Therapy: Careful joint mobilizations for ankle and foot joints to address stiffness (e.g., talocrural mobilization for dorsiflexion, subtalar mobilization for pronation/supination control). Soft tissue mobilization may be considered away from the wound bed to improve tissue extensibility.
• Footwear Prescription and Modification: Collaborative work with an orthotist to ensure appropriate therapeutic footwear and custom insoles for ongoing pressure redistribution and support.

Phase 3: Advanced Training and Return to Activity (Remodeling/Maintenance Phase)

Goal: Optimize functional independence, prevent recurrence, and integrate into a more active lifestyle.

• Progressive Exercise Program: Advance strength, endurance, and balance exercises.
• Incorporate functional movements, agility drills, and sport-specific training as appropriate, always prioritizing foot protection.
• Cardiovascular conditioning if cleared by physician and appropriate for patient comorbidities.
• Advanced Gait Analysis: Fine-tune gait patterns with new footwear and orthotics. Use video analysis to identify subtle biomechanical deviations.
• Recurrence Prevention Education: Intensify education on lifelong foot care practices.
• Emphasize the importance of consistent daily foot inspections.
• Proper nail care and skin hydration.
• Prompt reporting of any new blisters, redness, or skin breaks.
• Understanding the risk factors for recurrence and proactive management.
• Activity Modification: Guidance on safe participation in work, hobbies, and recreational activities, stressing appropriate footwear and activity pacing.
• Psychosocial Support: Address any fear of re-injury, anxiety, or depression that may arise from chronic wound management.

Phase 4: Long-Term Maintenance and Prevention

Goal: Sustain wound healing, prevent new ulcers, and empower long-term self-management.

• Ongoing Education and Reinforcement: Regularly reinforce all aspects of foot care, glycemic control, and activity modification.
• Regular Follow-ups: Periodic physical therapy assessments (e.g., sensation testing, footwear review, gait analysis, ROM checks) to monitor risk factors and intervene early.
• Home Exercise Program (HEP): Ensure patient adherence to a lifelong HEP to maintain ROM, strength, and balance gains.
• Footwear and Orthotic Monitoring: Regular inspection of shoes and orthotics for wear and tear, proper fit, and continued effectiveness in offloading. Patients often require new footwear or orthotics annually.
• Interdisciplinary Collaboration: Maintain strong communication channels with the podiatrist, endocrinologist, orthotist, and primary care physician to ensure holistic and coordinated care.
• Patient Advocacy: Empower patients to be active participants in their care, to self-advocate, and to seek immediate medical attention for any concerns.

4. Research

Evidence-based practice underpins all aspects of physical therapy in diabetic ulcer care. Extensive research supports the efficacy of key interventions:

• Offloading: Numerous studies and clinical guidelines consistently identify total contact casting (TCC) as the most effective method for healing plantar DFUs, demonstrating significantly higher healing rates and shorter healing times compared to other offloading devices. Research continues to refine offloading strategies for various ulcer locations and patient presentations.
• Therapeutic Exercise: While direct evidence for exercise on ulcer healing is complex due to the confounding effect of offloading, research strongly supports therapeutic exercise for improving patient-level outcomes. Studies show that targeted exercise programs improve ankle range of motion (crucial for reducing forefoot pressure), enhance foot muscle strength, improve balance and gait stability (reducing fall risk and abnormal biomechanics), and promote overall cardiovascular health, all of which indirectly support wound healing and prevent recurrence.
• Adjunctive Modalities: The efficacy of electrical stimulation (particularly HVPC) for wound healing is well-documented in systematic reviews and meta-analyses, showing accelerated wound closure. Therapeutic ultrasound also has a growing body of evidence supporting its role in enhancing tissue repair processes.
• Patient Education: Research consistently highlights that comprehensive patient education, tailored to individual learning styles and reinforced over time, is paramount for improving adherence to offloading, daily foot care, and glycemic control, thereby significantly reducing ulcer recurrence rates.
• Multidisciplinary Approach: Studies consistently demonstrate that integrated multidisciplinary care, involving physical therapists, podiatrists, endocrinologists, vascular surgeons, and wound care specialists, leads to superior DFU healing rates, reduced amputation rates, and better long-term outcomes compared to fragmented care.

Ongoing research is exploring novel biomechanical interventions, advanced wound healing technologies, and long-term prevention strategies to further enhance the role of physical therapy in combating the devastating effects of diabetic foot ulcers.