Management of the Diabetic Foot: Preventing Amputation

Marvin E. Levin, MD


South Med J. 2002;95(1) 

In This Article

Peripheral Arterial Disease

The atherosclerotic plaques that occur in patients with diabetes are no different than those occurring in the nondiabetic; in both, such plaques are composed of deposits of cholesterol, calcium, lipids, smooth muscle cells, and macrophages. There are, however, some important differences in the characteristics of PAD in these two groups of patients; these differences are listed in Table 2 .

Patients with diabetes should have a vascular examination at least once a year, while those who have evidence of PAD should be examined at least every 4 months. The most important steps in evaluating PAD are a medical history and a thorough vascular examination. In general, a history of intermittent claudication is one of the first symptoms of vascular insufficiency. Because of loss of sensation, however, diabetic patients may have ischemia without symptoms. Coldness of the foot and absence of pulses are hallmark clinical signs of PAD, as are shiny, atrophic skin and loss of hair.

Epidemiology Of Diabetic Foot Ulcer
  • 16 million diabetics

  • 15% have foot ulcers

  • 6% require hospitalization

When the medical history and physical examination reveal signs or symptoms of ischemia, the vascular laboratory can be of help. Patients with diabetes may have normal ankle pressures but significantly decreased toe pressures. It is extremely important, therefore, to measure toe pressures in patients with diabetes. Arterial waveforms as well as segmental pressures help to indicate areas of arterial narrowing.

Telling patients with PAD not to cross their legs is of little protective value. A study of diabetic patients with known PAD showed that crossing their legs did not decrease Doppler pressures.[8]


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