Diabetic foot ulcers: The pressure

Diabetic foot ulcers (DFU)

Foot ulcers are poor to non-healing full thickness wounds found around the patient’s ankle to plantar surface. Diabetic patients have a 25% likelihood of developing a foot ulcer, making this one of the most common form of complications. Once developed, the treatment and management of these wounds are considerably complicated and naturally dynamic. The risk of developing these ulcers are increased by:

  • Irritated or wounded feet: Diabetic patients are particularly vulnerable to irritation and/or injuries to their feet due to weakened skin. Mild irritations/injuries can stem from ill-fitting footwear to a stone in the shoe which can cause a breakage in weakened skin. These irritations can easily develop into a wound, which becomes difficult or impossible to heal. When accompanied by the factors identified below, the diabetic foot easily becomes an ideal ground for foot ulcers to develop.
  • Diabetic neuropathy: In particular, peripheral neuropathy which is the most common form of nerve damage amongst diabetic patients. This can either cause pain or loss of feeling in key sensory areas i.e. feet, toes, hands etc. making it difficult to impossible to feel any form of irritation, development of a blister, or any wounds that may lead to a foot ulcer.
  • Ischaemia: In reference to diabetic foot ulcers, poor blood circulation limits the efficient flow of blood to the feet, making it difficult for a wound to heal. The unhealed wound increases the likelihood of developing an infection which can lead to a fold of further complications.
  • High blood sugar: there is a strong correlation between maintaining normoglycaemia (normal blood sugar levels) and the rate of wound healing. Inadequately high levels can lead to a narrowing of blood vessels and a stiffening of the arteries which consequently makes it difficult for oxygen to properly flow to the affected area. High glucose levels may also impair the effectiveness of immune cells which increases the risk of infection for the patient when a wound is present.  


The pressure of diabetes related foot ulcers

A foot ulcer diagnosis can exact a heavy toll on the patient’s quality of life and can be emotionally challenging due to the fear of an impending amputation. Of the 70% of patients that present neuropathy, 25% of cases are likely to develop into a foot ulcer. Of these foot ulcers, 50% will become infected, leading to 20% of cases requiring some form of amputation.

A recent study by Marion Kerr exploring diabetic foot care in England suggests both amputations and foot ulcers are associated with a higher mortality rate. Patients who have suffered from a foot ulcer reportedly have a less than 60% five year survival rate. More drastically, for those who’ve experienced a major amputation, survival rates are around 50% for the two years that follow the surgery.

An average of 60,000 – 75,000 people in England are estimated to have foot ulcers. This is an evident cause for concern given numerous reports have stated diabetes dramatically increases the risk of amputation. A case study by Diabetes UK supports this statement as it highlighted 80% of amputation cases are preceded by a foot ulcer.


In the UK, 135 people undergo a diabetes related amputation every week.  


Diabetic foot ulcers patient pathway

Diabetic patients in England are introduced to the care pathway through their GP. The care plan is dependent on the level of risk the patient poses of developing a foot ulcer, key risk factors can be identified in the initial paragraph but can be further explored at: diabetes.org.

NICE guidelines suggest, patients should be referred to a foot protection service team when they pose a moderate to high risk of developing a foot ulcer. Thereafter, a specialist not only provides advice about foot care, but assesses the biomechanical status of the feet, to calculate the need to prescribe specialist footwear and/or orthoses to prevent DFU from occurring.

Issues faced in the care pathway.

  • Custom insoles can take a number of weeks to get made; thereafter they must be fitted, tested and adjusted which involves several appointments with the podiatrist.
  • The foam material used to manufacture insoles are made from multiple layers meaning they are often bulky and can only be used with therapeutic footwear. No one enjoys wearing this, and it often leads to issues with self-esteem and non-compliance reducing effectiveness.
  • The foam compresses with use and insoles must be replaced every 12 months; custom footwear is also expensive ranging from £150-£250 a pair, when out of pocket, this can prove relatively expensive.  

Macro-economic issues

Diabetic foot disease is the most common reason a diabetic is admitted to hospital.


The costs associated with foot ulcers and amputations are introducing significant cost pressures to the NHS, evidenced by £972m – £1.13bn yearly spend. The high expenditure is justifiable given diabetic foot ulcers are multifactorial, hence demand high levels of care to limit mortality and other consequences. However, as the number of cases are expected to rise to 5 million by 2025, expenditure on foot ulcer care is under scrutiny.

Because of a low supply of specialists (podiatrists and orthotists), GP’s find it difficult to always refer individuals for a diabetic foot related risk assessment. The delay in services exacts pressure on the chain of care given the longer it takes to be seen, the more severe ulcers can become. Consequently, healthcare providers face significant time and care pressures when dealing with patients suffering from diabetic foot ulcers. Insufficient capacity has also led to negative geographic dispersion of specialists. Patients may be more reluctant to attend appointments due to distance to a specialist, making it difficult for the foot protection service team to carry out continuous check ups.


For information on how bespoke insoles can be designed to alleviate some of the pressures faced with diabetic foot ulcer prevention read about our Imprints system here.

For comprehensive patient guides on diabetic neuropathy access EndocrineWeb.com

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