Forefoot Ulcer

Diabetic Forefoot Ulcer

What is a diabetic forefoot ulcer?

A diabetic forefoot ulcer is a wound that develops on the front part of the foot (usually under the toes or ball of the foot) due to increased pressure on the skin.

It most commonly occurs in people with diabetes-related nerve damage (peripheral neuropathy).
Neuropathy reduces sensation and alters foot mechanics, so areas of high pressure are not felt and the skin gradually breaks down.

Poor blood circulation may also contribute and delay healing.

Why does it happen?

Diabetes can affect:

1. Nerves – loss of protective sensation
   Small injuries go unnoticed
2. Foot shape and muscles – bony prominences develop
   Increased pressure under specific points
3. Skin – callus forms first, then ulcer

Most ulcers therefore develop in one of two ways:

• Minor unnoticed injury
• Thick callus breaking down due to pressure

Symptoms

Many patients feel little or no pain because of neuropathy.

Common signs include:

• Hard skin (callus) under the foot
• Blood staining inside socks
• Wound under a toe or ball of foot
• Swelling or redness
• Discharge or odour (suggests infection)

Investigations

• X-rays: check bone alignment, deformity and gas or bone damage
• MRI scan: assesses infection and confirms osteomyelitis (bone infection)

Treatment

Initial (non-operative) treatment

This is the most important stage and is led by the multidisciplinary diabetic foot team:

• Pressure off-loading (special footwear, cast boot or custom orthosis)
• Regular podiatry debridement of callus
• Wound dressings
• Infection control if required

Many ulcers heal with correct off-loading alone.

When is surgery needed?

If the ulcer persists or keeps recurring despite good off-loading, surgery may be recommended.

The procedure depends on the underlying cause and may include:

• Removal of infected or dead tissue (debridement)
• Correction of bony prominence (osteotomy)
• Tendon balancing to reduce pressure

Surgery aims to remove the pressure source, not just close the wound.

Important message

A diabetic ulcer is a pressure problem, not just a skin problem.
Unless pressure is permanently reduced, ulcers frequently return.

Early treatment greatly reduces the risk of infection, hospital admission and amputation.