Diabetic foot syndrome

Overview: What is Diabetic Foot Syndrome?

Diabetic foot syndrome refers to tissue damage to the foot that occurs in people with diabetes as a result of a combination of nerve damage, poor blood circulation and increased susceptibility to infections. Typical symptoms include painless pressure points, poorly healing wounds, corneal thickening, misalignment and, in the case of advanced nerve damage, Charcot foot (neuroarthropathic joint destruction). From an orthopedic point of view, it is crucial to recognize pressure and incorrect loads and to consistently relieve them using aids, bandages and appropriate footwear.

• Main risk factors: long-standing diabetes, elevated blood sugar levels (HbA1c), smoking, previous foot ulcers/amputation, PAD, limited feeling.
• Core problems: Loss of pain warning function, changed pressure distribution, fragile skin, delayed wound healing.
• Goals of treatment: pressure relief, infection control, optimization of blood circulation and metabolism, recurrence prevention.

Causes and pathophysiology

DFS is usually not caused by a single cause, but by an interaction of several factors. These cause each other and increase the tissue damage.

• Diabetic polyneuropathy: Decreased sensation of pain, vibration and temperature; Changed muscle balance with misaligned toes (claw toes), which creates local pressure peaks.
• Peripheral arterial disease (PAD): Reduced blood flow in small and large vessels reduces oxygen and nutrient supply; Wounds heal more slowly and infections occur more easily.
• Mechanical pressure and shear forces: Tight, hard or new shoes, longer walking distances without getting used to it, hard skin on the soles of the feet (hyperkeratosis) - everything increases local tissue stress.
• Infections: Often polymicrobial; favored by wound pockets, necrosis, limited immune defense. Risk of osteomyelitis (bone infection) in deep or probable wounds.
• External factors: smoking, unbalanced blood sugar, kidney failure, lack of foot care and lack of training.

Symptoms and warning signs

The tricky thing about DFS: Wounds often cause little to no pain. Therefore, pay attention to visible signs and changes.

• Skin lesions: redness, blisters, calluses with a dark core, rhagades (tears), weeping areas, odor.
• Sores/ulcers: Common under the forefoot (heads 1-5), on the tips of the toes, heel or on the side of the foot; some with callus collar.
• Signs of infection: Increasing redness, overheating, swelling, sensitivity to pain despite neuropathy, secretion, fever/chills.
• Signs of blood circulation: cold foot, pale skin, lack of pulse, pain in the calf (claudication), pain at rest.
• Charcot suspicion: warm, red, swollen, often painless, unstable foot without an open wound - orthopedic emergency.

Immediate medical evaluation is necessary if: rapidly increasing redness/swelling, fever, foul-smelling wound, visible exposed bone/tendon, cold, pale foot with severe pain.

Diagnostics: structured and guideline-oriented

A systematic examination helps to identify risk profiles, assess the extent and determine the correct treatment strategy.

• Medical history: Duration of diabetes, HbA1c, previous ulcers/amputations, smoking, vascular diagnostics, footwear, walking circumference, home support.
• Inspection: skin, nails, calluses; location and depth of wounds; signs of infection; Odor; Shoe and stocking check.
• Neurological tests: 10 g monofilament (touch sensation), 128 Hz tuning fork (vibration), temperature sensation; If necessary, reflex and motor skills testing.
• Vascular: foot pulses, ankle-brachial index (ABI), Doppler, if necessary transcutaneous oxygen measurement (tcPO2) or duplex sonography.
• Imaging: X-ray for deformity/suspected Charcot or chronic wound; MRI for suspected osteomyelitis; if necessary CT for planning.
• Laboratory: inflammation levels (CRP, leukocytes), kidney function, blood sugar/HbA1c.
• Wound swab/tissue culture: Only useful in clinical infection; ideally from cleansed, deep tissue, not from the surface.
• Risk classification: Classification according to common schemes (e.g. Wagner, PEDIS) for therapy planning and follow-up monitoring.
• Pressure analysis: Podography/in-shoe pressure measurement to identify pressure peaks and optimize the insoles/shoes.

Conservative treatment: pressure relief, wound, infection, blood circulation

Conservative measures come first. They aim to protect tissues, promote wound healing and control infections. The specific selection depends on the depth/location of the wound, location of the infection, blood circulation status and mobility goals.

Healing times vary – often several weeks to months depending on depth, blood flow and stress. Consistency with offloading and wound care is crucial.

Treat in an interdisciplinary manner – safety through teamwork

The DFS benefits from coordinated care. Depending on the findings, we work with diabetology, angiology/vascular surgery, infectious diseases, podiatry, orthopedic technology and family doctors. In this way, wound healing, blood circulation, infection control and the provision of aids can be coordinated.

• Common goal definition: wound closure, preservation of function and mobility, prevention of recurrence.
• Clear milestones: reduction in inflammation, granulation formation, gradual increase in load.
• Regular progress control: photo and measurement documentation, adjustment of dressings and offloading.

Orthopedic aids and shoe care

Correctly selected tools are often the key to success. They reduce pressure peaks, stabilize and protect the foot - both in the acute healing phase and to prevent further wounds.

• Acute phase: forefoot relief shoes, heel relief shoes, TCC/Walker, soft positioning bandages with pressure-relieving padding.
• After healing: Diabetic protective shoes with soft, seam-free inner lining; custom-made pressure redistributing inserts; If necessary, custom-made shoes for deformities.
• Pressure measurement for fine adjustment: In-shoe measurements help to adjust insoles and footwear objectively.
• Charcot foot: In the active phase, usually lower leg immobilization (e.g. TCC/Walker); later stable orthoses (e.g. CROW).

Surgical options – restrained and targeted

Operations are carefully considered at DFS. Conservative measures have priority. Surgical interventions are considered when infections need to be drained/debrided, bone infections need to be repaired, or severe misalignments permanently disrupt the distribution of stress.

• Surgical debridement/abscess relief for extensive infection or necrosis.
• Treatment of osteomyelitis: tissue and, if necessary, bone removal with consistent follow-up treatment; Antibiotic therapy according to resistance level.
• Revascularization: Vascular medical procedures to improve blood circulation (interdisciplinary).
• Corrective and reconstructive procedures: Only after the inflammation has subsided; The goal is a plantigrade, resilient foot shape. Indications are individual and reserved.
• Amputation: Ultima ratio for uncontrollable infection, extensive necrosis or critical ischemia - as tissue-sparing as possible and with subsequent prosthetic/orthopedic care.

Regenerative processes (e.g. PRP) play a minor role in DFS and are only used in selected situations and in addition. The basis remains consistent pressure relief and infection/circulation control.

Prevention: What you can do yourself every day

Many DFS complications can be avoided through consistent foot care and appropriate behavior. Training and routine are crucial.

• Daily inspection: Check the soles of the feet, between the toes and heels - use a mirror or help.
• No self-therapy with sharp blades or caustic callus products; Prefer podiatric specialist care.
• Avoid walking barefoot – even in the apartment. Check the inside of your shoes for foreign objects before putting them on.
• Socks: Seamless/fine, change daily; no constricting cuffs.
• Footwear: Soft, sufficiently wide and long, worn in; If in doubt, have it adjusted orthopedically.
• Skin care: Apply cream daily (not between the toes), avoid cracks; watch for signs of fungus.
• Nails: Cut straight, do not tear out corners; If you suspect ingrown nails, get help early.
• Lifestyle: Stop smoking, regular exercise without overloading your feet, stable blood sugar control, sufficient fluids.
• Regular checks: Depending on the risk, orthopedic/diabetological foot checks every 3-6 months.

Course, healing time and everyday life

The prognosis depends largely on blood flow, infection location, wound depth, offloading consequence and metabolic control. For superficial, well-relieved ulcers, healing can often be achieved in weeks; deeper or infected wounds tend to take months. Relapses are possible, which is why recurrence prevention and shoe/insole checks are crucial.

• Work and sport: Strictly reduce stress in the acute phase. Increase slowly after healing; Prefers activities that are gentle on the joints (e.g. cycling on an exercise bike with pressure-relieving pedal settings, swimming, strength training without foot pressure).
• Pain management: Neuropathic pain is addressed individually; However, warning signs and function are often the focus.
• Aftercare: Regular foot checks, insoles/shoe checks, repeat pressure measurements, training refresher.

Checklist: First steps for a new pressure point or wound

When should you see a doctor?

• Immediate: Rapidly increasing redness/swelling, fever/chills, strong odor, exposed bone/tendon, cold pale painful foot.
• Within 24-48 hours: New wound, blister or deep crack; Suspected Charcot foot (warm, red, swollen, unstable foot).
• Regularly: Foot check every 3-6 months – depending on the risk class.

Orthopedics in Hamburg-Winterhude: Our approach

At Dorotheenstrasse 48, 22301 Hamburg, we care for patients with diabetic foot syndrome with a focus on conservative orthopedics. We combine careful diagnostics, consistent pressure relief, modern wound care and close collaboration with diabetology, angiology and podiatry.

• Structured examination including neuropathy and vascular screening.
• Individual offloading concepts (shoes, insoles, orthoses, if necessary TCC/Walker).
• Standardized wound treatment plans with progress documentation.
• Quick coordination of external partners for vascular or infection issues.
• Transparent information without promises of cure – realistic goals and joint decisions.