Foot syndrome diabetic E10.70 oder E11.70

Complex of pathological symptoms localised on the feet, which are directly or indirectly considered to be the consequence of diabetes mellitus, which is usually a long-term condition. The symptoms in detail: bacterial and mycotic infections, pressure-related ulcerations (see Malum perforans) and/or destruction of deep tissue areas, severe neuropathic disorders of the foot up to complex osseous destruction (see Charcot arthropathy), complicated, diabetes-induced peripheral arterial circulatory disorders of varying degrees ( PAD).

Classification according to Wagner:

• Risk foot, no ulceration, possibly foot deformity
• Superficial ulceration (usually due to improper footwear; see Malum perforans below)
• Foot deformity
• Deep ulcer to the joint capsule, tendons or bones
• Deep ulcer with abscess, osteomyelitis or infection of the joint capsule
• Limited necrosis in the forefoot or heel area
• Necrosis of the entire foot.

4-10% of patients with diabetes mellitus suffer from DFS.

Glycation (non-enzymatic glycosylation) leads to uncontrolled storage of glucose in numerous tissues, e.g. in vessels, nerves, connective tissue, etc..

The consequences are:

• autonomic, motor and sensory nerve disorders (diabetogenic neuropathies)
• Immunosuppression due to glycation of immunocompetent cells (especially macrophages, leukocytes)
• Changes in the flow properties due to an increase in the viscosity of the blood
• Macroangiopahies (carotid artery, large vessels of the legs: PAVK, typically below the knee).

Risk factors for diabetic foot syndrome are:

• Long duration of diabetes:
• High blood glucose levels
• Hypercholesterolemia
• Nicotine abuse
• Presence of retinopathy, nephropathy or neuropathy
• Decreased sensitivity
• Callus formation due to incorrect stress (not painful or only less painful due to neuropathy)
• Reduced muscle strength (limited stabilization of the foot)
• Manifest leg ulcer or ulcer in the anamnesis
• Arterial hypertension
• Lack of exercise
• CVI (chronic venous insufficiency with reduced joint mobility in the ankle joint - arthrogenic congestion syndrome)
• Reduced joint mobility
• Plantar hyperkeratosis
• Unsuitable footwear.

Initial: Warm, dry, red feet with reduced sensitivity, usually with pronounced callus formation at pressure points.

Progressive: Formation of polyneuropathic, painless ulcers on pressure-exposed areas of the foot (see below Acropathia ulcero-mutilans non-familiaris).

Late complications:

• Infections: mycotic and bacterial infections of varying severity (erysipelas, gram-negative foot infection, foot phlegmon, necrotizing fasciitis, osteomyelitis).
• Charcot arthropathy
• Increasing disease-induced, enforced immobility of patients with its secondary symptoms.

Careful inspection of the feet: neuropathic, non-painful ulcers occurring at pressure points are the typical leading symptom of diabetic foot syndrome

Specific anamnesis

Examination of touch sensitivity

Foot pulses

Ankle-arm index

If necessary, radiological diagnostics: DSA or angio-MRI.

The therapy is based on several pillars:

• Diabetes Optimization
• Pressure relief
• infection control (bacteriological monitoring, also gram-negative germs, e.g. Escherichia coli)
• modern wound management with wound cleansing, if necessary necrosectomy
• Consistent and situation-adapted therapy of the vascular disease.

Wound dressings with silver-activated charcoal overlays are recommended for wound treatment. Later, granulation of the wound can be promoted with a calcium-alginate dressing. Depending on the severity of the damage, minor amputations may be necessary. Education of the patient (wound and diabetes education).

1. Hertel T et al (2014) Diabetic foot syndrome. Skin14:190-195
2. Cracks A (2014) The diabetic foot syndrome. Vasomed 26:191-196