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A diabetic foot ulcer is an open wound on the foot that occurs in someone who has diabetes. Diabetic foot ulcers can occur from scrapes in the skin, blisters, fissures, and excessive pressure on certain parts of the foot.
In people who do not have diabetes, a sore can heal in a few days. However, in diabetics, foot ulcers can take a lot longer to heal. Even with the best medical care, healing a diabetic foot ulcer can be stalled due to several reasons.
Chronic wounds cost a huge amount of money to treat, with important effects being the number of lost work days, decreased productivity, and disability payments plus the additional cost of rehabilitation (1).
It’s important to heal wounds as soon as possible to avoid infections and amputation.
In this article, you’ll learn all the different reasons why diabetic foot ulcers don’t heal and solutions on what you can do if you suffer from non-healing foot ulcers yourself.
Let’s dive in…
1) Diabetic Foot Ulcers May Not Heal Due to Neuropathy
When someone is neuropathic, they are not able to feel the bottoms of their feet when they are walking. Neuropathy symptoms can manifest as tingling, burning, or a completely numb sensation. Constantly elevated blood sugar levels in diabetics can damage the nerves in the feet over time.
People have different levels of neuropathy. Some people may feel mild neuropathy symptoms with some tingling in their feet. Others may have moderate neuropathy symptoms where part of their feet may be numb. Others may suffer from severe neuropathy where they cannot feel the bottoms of their feet at all.
The problem with neuropathy is that it can manifest in many ways. Some people may not be able to feel touch sensation, some may not feel vibration sensation, and some cannot even feel the difference between hot and cold.
The human body relies on pain receptors to notify the brain of insult or injury to the body. if you do not have sensation in the bottoms of your feet, you are at a much higher risk of developing a foot ulcer. Your body is simply unaware that it is hurt and undergoes further damage.
If you have a foot ulcer, your doctor is likely treating the ulcer regularly. He/she will instruct you to apply topical medication or grafts onto the ulcer to stimulate healing. You may be instructed to stay off of your foot in a special surgical shoe or below-knee boot.
The problem with this is that it can be incredibly difficult to stay off of your foot for a long time. People with neuropathy also suffer from balance issues which can put them at risk for falls. You may have a harder time using crutches or a walker.
What if you have a foot ulcer in between your toes?
It can be difficult to determine whether the foot ulcer is healing or getting worse when you can’t feel the area between your toes.
To learn more about neuropathy, read the Ultimate Guide For Nerve Pain In the Foot.
Solution
Offload offload offload!
As I mentioned previously, diabetic foot ulcers often occur due to excessive pressure on the bottoms of your feet. If you have an ulcer in between your toes, you likely developed it due to the bones in your toes rubbing against each other.
Now I mentioned that staying off of your foot for prolonged periods can be difficult. However, you can still take pressure away from your ulcers by using the correct offloading pads.
Offloading wounds can be immensely helpful to remove pressure from the ulcer in a consistent way, and still allow you to bear some weight.
If you have an ulcer on the bottom of your foot, your doctor may suggest you wear an offloading U-pad to help alleviate pressure from the ulcer when you are walking. These adhesive pads are disposable and can be used to keep pressure away from the sore. They can be found on Amazon.
You can even use ¼” felt to construct offloading donut pads yourself. Buy them in bulk and construct your own. The goal is to keep pressure away from the sore so it can heal faster.
If you have an ulcer on the top of your toe or in between your toes you can use an offloading corn pad to alleviate pressure. Put the hole of the pad where the ulcer is located. This will keep shoes from rubbing on your toe ulcer.
What if you have an ulcer in the bottom of your heel? If this is the case, you can obtain a heel offloading surgical shoe that will alleviate pressure on your heel. Be careful with this because it can throw off your balance. You should only use these types of surgical shoes if your balance is good. You will want to make sure to walk slowly while wearing this shoe.
If you have an ulcer in the bottom front part of your foot, you can wear a forefoot offloading surgical shoe. Again, this should only be used if your balance is good.
If you have ulcers on the insides and outer parts of your feet, check your shoes to make sure that they are wide enough. If your shoes are too narrow or too constrictive, you may not even realize that they are causing foot ulcers to form.
In this case, diabetic shoes and diabetic insoles can be beneficial. You can talk to your foot doctor about whether you would qualify for a pair. Occasionally, insurance may cover 1 pair of diabetic shoes with 3 pairs of inserts a year.
When you obtain a diabetic shoe, you should have your feet measured for length and width. This can be done at your doctor’s office. Then you should obtain a shoe that is extra depth and wide enough for your feet so that it can accommodate any foot deformities you may have.
Diabetic shoes are constructed in a way not to irritate sensitive skin. Diabetic insoles are designed for shock absorption and comfort in people who have neuropathy. Custom diabetic insoles can be used to offload diabetic foot ulcers using extra padding. These can be incredibly helpful to heal a foot ulcer.
If you have developed a diabetic foot ulcer on the back of your heel or bottom of your heel secondary to pressure while sleeping or in a wheelchair, you will need to offload your heel. You can do this using a heel protector cushion boot. This is a cushioned boot that will help alleviate pressure from the heels.
Another alternative to offload the back of your heels while sleeping is to place pillows under your legs to prevent pressure on the back of your heels.
Make sure to check the bottoms of your feet every day as well as the skin between the toes. This must be done daily if you suffer from neuropathy. If you cannot reach down to check your feet have someone help you.
If you live alone, put a mirror against a wall and lift your feet so that you can check your feet. Performing regular foot exams can go a long way to preventing diabetic foot ulcers.
If you have an ulcer, make sure to look at it regularly to check for signs of infection. If you notice pain in the foot, redness, pus, black or grey color in the ulcer, or a bad smell, you should alert your doctor immediately. You may need antibiotics or even surgery.
2. Hyperglycemia Can Cause Your Foot Ulcer Not to Heal
If you have chronic, elevated blood sugar levels, this can hinder wound healing. When your blood sugar levels are elevated from diabetes, it can affect the phases of wound healing that allow your ulcer to heal.
Not only that, hyperglycemia correlates with stiffer blood vessels which cause slower circulation (2). This reduces tissue oxygenation to the wound and can affect wound healing.
Blood glucose levels vary from day to day, and can change before and after eating meals.
It is important to check your Hemoglobin A1c. This is the average blood sugar level over the last 3 months. A normal Hemoglobin A1c is 5.7. That is a blood sugar level of 117mg/dL. You can look at the conversion table here.
Solution
If you struggle with elevated blood sugar levels, it’s important to work with your Family Doctor or Endocrinologist regarding medications that can help you manage your blood sugar levels.
AWARENESS IS KEY.
Some people do fine with checking their blood sugar levels 3 times a day. Their sugars may not fluctuate because they are used to eating consistent meals.
Others who struggle with their diet may suffer from fluctuating blood sugar levels. If this is the case, you may want to have a discussion with your doctor about obtaining a glucose monitor that will check your blood sugar levels throughout the day and notify you of large fluctuations. Nowadays, you can even obtain blood sugar monitors that don’t require a finger prick.
Try your best to maintain your diet. As far as sugar is concerned, the American Heart Association recommends that men should consume no more than 9 tsp of sugar a day, and women should consume no more than 6 tsp a day.
It’s also important to manage your carbohydrate intake. Aim to increase your protein intake as well as veggies. You can read more about diabetes meal planning recommended by the Centers for Disease Control and Prevention.
If you still struggle with your diet, talk to a Dietician about recommendations. There are also many local Diabetes support groups that you can join to help you on your journey.
3. Peripheral Vascular Disease Can Cause Wound Healing to Be Delayed
Peripheral vascular disease (PVD) is a circulation disorder that occurs due to narrowing or blockage of the arteries leading to the foot.
People who are at high risk for PVD include people who are diabetic, have a positive smoking history, history of high blood pressure and high cholesterol.
If you have a foot ulcer and do not have adequate blood flow going to the foot to help perfuse the wound, your wound healing may be delayed significantly. Not only that, people who have very poor blood flow in their feet and their toes may experience painful ulcers in the tips of their toes and other areas of their feet. These are arterial ulcers.
Even if you have neuropathy, arterial ulcers can be painful due to blockage of blood flow.
Solution
When you are at your doctor’s office, your doctor will try to feel the pulses in your feet and ankle. If they are not able to feel your pulses, they may send you to get an arterial doppler. An arterial doppler ultrasound is a non-invasive test that can be done to check blood flow in the feet. It is painless and fast.
If you have poor blood flow, your doctor may refer you to a Vascular Surgeon or Interventional Cardiologist to receive recommendations for surgery. In some cases, you may need an angioplasty to open your leg arteries and improve blood flow to the feet.
4. Obesity Can Hinder Wound Healing in People Who Suffer From Diabetic Foot Ulcers
When you have elevated blood sugar levels, it may contribute to weight gain. The problem with weight gain is that excessive weight can hinder wound healing.
There are set phases of wound healing. For the appropriate cellular processes to occur to heal a wound, proteins, minerals, and vitamins are needed. This requirement places obese patients at a disadvantage because they suffer from “paradoxical malnutrition resulting from a calorie-dense diet that is high in carbohydrates and fats and low in vitamins and minerals” (3). This reduces the body’s ability to heal wounds.
When it comes to the feet, every extra pound can create excess pressure on the bottoms of your feet. If you have numbness in your feet and have a diabetic foot ulcer, this excess pressure can cause a delay in wound healing.
Solution
It’s important to manage your diet and exercise regularly. The Physical Activity Guidelines for Americans recommend 150 minutes of physical activity a week with 2 days of muscle strength training.
Managing your diet is important. Make sure to speak to a Dietitian for advice if you struggle with your diet. The American Diabetes Association also provides free meal plans/recipes that you can check out to help you stay on track.
5. Kidney Disease
People with diabetes often develop kidney disease. Kidney disease has been long known to affect wound healing. People with chronic kidney disease show “less cellular proliferation and angiogenesis with concurrent derangements in inflammation during the early stage of wound healing” (4). This means that the wound remains inflamed and is unable to develop new blood vessels to help heal it.
Not only that, people who have the end-stage renal disease have been shown to have protein malnutrition (5).
Solution
Make sure that you are following up with your doctor regularly to get blood work done. Your doctor will be looking at your creatinine levels. This checks to see how well your kidneys are working by checking the creatinine levels in your blood. Your doctor will also order a urine test, and may even order an ultrasound. Your doctor may also recommend you see a Nephrologist, a doctor who specializes in treating kidney disease.
6. Nutritional Defects Can Delay Wound Healing
Nutrition can play a large role when it comes to wound healing. Poor nutrition can result in your foot ulcer not healing. Wounds need vitamins, minerals, and proteins to help them heal. If you suffer from nutritional deficiencies, wound healing can be stalled.
Malnutrition is defined as a pre-albumin of less than 15 mg/dL or a decrease in one’s total body weight by more than 5% experienced within 1 month (6).
Solution
You will need to follow up with your doctor regularly to get blood tests done to diagnose nutritional deficiencies.
If you develop malnutrition, your doctor will recommend you consume protein in the amount of 1.2–1.5 gm/kg of body weight every day.
Your doctor may also recommend certain supplements that you can take that assist with wound healing. It has been shown that Vitamin D and B-complex vitamins may be effective in the healing of foot ulcerations (7).
7. Poor Footwear Can Impede Wound Healing
The importance of footgear when you have a foot ulcer becomes incredibly important. Your doctor may recommend that you wear diabetic shoes and diabetic insoles (as mentioned previously).
However, there may be instances where you may wish to wear regular shoes. If you choose to wear your shoes, make sure you are wearing the correct size.
You will need to get your feet measured at the end of the day when your feet are the most swollen. You need to measure the length and width of your feet. This can be done using a Brannock Device.
Here’s a video by SanLuis Podiatry demonstrating how to use a Brannock Device properly.
Shoes should never be too constrictive and rub uncomfortably against your feet. You will need to examine the bottoms of your shoes monthly to look for any signs of wear and replace your shoes accordingly.
Read about How Bad Shoes Can Cause Foot Pain.
The skin in diabetics is very sensitive. Even socks can cause discomfort in the legs.
Diabetic socks work great because they are non-binding and are breathable.
Conclusion
As you can see, there are a variety of reasons why your diabetic foot ulcer may not be healing. It’s important to consider every factor when treating a diabetic foot ulcer.
It can be incredibly frustrating to go months without healing an ulcer when something could have been done to speed up the healing process. With these tips, you can be better prepared to help manage your diabetic foot ulcer.
Have you ever had a diabetic foot ulcer? What helped heal it? I would love to hear your thoughts! Leave a comment below!
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Related articles:
Incision and Drainage of Foot: What a Foot Abscess Drainage Entails
Actionable Solutions For Foot Problems From Diabetes
Diabetic Neuropathy in the feet- A Simple Treatment Guide
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References
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- Dinh T., Elder S., Veves A. Delayed wound healing in diabetes: Considering future treatments. Diabetes Manag. 2011;1:509–519. https://www.openaccessjournals.com/articles/delayed-wound-healing-in-diabetes-considering-future-treatments.pdf
- Ernst B, Thurnheer M, Schmid SM, Schultes B. Evidence for the necessity to systematically assess micronutrient status before bariatric surgery. Obes Surg. 2009 Jan;19(1):66-73.https://pubmed.ncbi.nlm.nih.gov/18491197/
- Seth AK, De la Garza M, Fang RC, Hong SJ, Galiano RD. Excisional wound healing is delayed in a murine model of chronic kidney disease. PLoS One. 2013;8(3):e59979.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3607571/
- Zha Y, Qian Q. Protein Nutrition and Malnutrition in CKD and ESRD. Nutrients. 2017 Feb 27;9(3):208.https://pubmed.ncbi.nlm.nih.gov/28264439/
- Andrews KL, Houdek MT, Kiemele LJ. Wound management of chronic diabetic foot ulcers: from the basics to regenerative medicine. Prosthet Orthot Int. 2015 Feb;39(1):29-39. https://pubmed.ncbi.nlm.nih.gov/25614499/
- Bechara N, Gunton JE, Flood V, Hng TM, McGloin C. Associations between Nutrients and Foot Ulceration in Diabetes: A Systematic Review. Nutrients. 2021 Jul 27;13(8):2576https://pubmed.ncbi.nlm.nih.gov/34444735/
- Margolis DJ, Hofstad O, Feldman HI. Association between renal failure and foot ulcer or lower-extremity amputation in patients with diabetes.
- Pierpont YN, Dinh TP, Salas RE, Johnson EL, Wright TG, Robson MC, Payne WG. Obesity and surgical wound healing: a current review. ISRN Obes. 2014 Feb 20;2014:638936. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3950544/#:~:text=The%20vascular%20insufficiencies%20and%20altered,micronutrient%20deficiencies%20in%20obese%20individuals.
- Okonkwo UA, DiPietro LA. Diabetes and Wound Angiogenesis. Int J Mol Sci. 2017 Jul 3;18(7):1419.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5535911/
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