Printer Friendly

A nurse's guide to the prevention of neuropathic ulcers in patients with diabetes.

Diabetic neuropathy is responsible for 85% of foot ulceration (Ndip, Ebah, & Mbako, 2012). Such neuropathic ulcers not only pose a high risk for amputation, but also contribute greatly to decrements in quality of life, impacting the ability to live independently (Howard, 2009; O'Loughlin, McIntosh, Dinneen, & O'Brien, 2010). Approximately 120,000 nontraumatic lower extremity amputations are performed each year, with 80% preceded by a neuropathic foot ulcer (Driver, Fabbi, Lavery, & Gibbons, 2010; Lavery, LaFontaine, Higgins, Lanctot, & Constantinides, 2012). Diabetes, which affects over 29.1 million people (Centers for Disease Control and Prevention [CDC], 2014), remains the chronic disease most often associated with amputation of the lower extremity (CDC, 2011; Nerone, Springer, Woodruff, & Atway, 2013). According to the CDC (2011), complications related to diabetes cost $245 billion annually. Discussion of neuropathic ulcer prevention thus is of vital importance to nurses due to the adverse impact on patient outcomes as well as hospitalization costs directly related to ulceration and subsequent amputation.

Because nurses are responsible for educating patients and family members about self-care and disease management, they are pivotal in assisting patients with neuropathic ulcer prevention. Understanding the etiology, risk factors, and evidence-based strategies for preventing neuropathic ulcers will assist nurses to identify persons at high risk for neuropathic ulcers, thus reducing patient morbidity and associated health care costs. The etiology, risk factors, and evidence for prevention of neuropathic ulcers in persons with diabetes are addressed.

Etiology and Risk Factors for Neuropathic Ulcers

A neuropathic ulcer is a skin wound occurring most often in patients with underlying metabolic conditions (e.g., diabetes) that cause loss of sensation of the lower extremities. Development of neuropathic ulceration of the lower extremity is the result of multiple risk factors. While the specific focus of this article is on neuropathic ulcer development as a consequence of diabetic peripheral neuropathy, it is important to note diabetes poses risks other than neuropathy that contribute to ulcer formation (American Diabetes Association [ADA], 2003).

Diabetic Peripheral Neuropathy and Peripheral Arterial Disease

Diabetic peripheral neuropathy (DPN) and peripheral arterial disease (PAD) account for most of the risk for neuropathic ulcer formation in persons with diabetes. Approximately 50% of persons with long duration of disease develop DPN (Tesfaye et al., 2011). Diabetic peripheral neuropathy involves alterations to the sensory, motor, and autonomic nerves responsible for multiple changes that result ultimately in neuropathic ulcer formation. Loss of sensation in the lower extremities prevents the patient from detecting pressure points and pain, leading to soft tissue plantar injury. A study by Gonzalez and colleagues (2010) found a 19% rate of ulcer formation over an 18-month period.

Affecting the smallest muscles of the feet, motor neuropathy predisposes the individual to foot deformities such as hammer toe and limited joint mobility, further increasing the risk for neuropathic ulcer formation. DPN also affects autonomic nerves that regulate perspiration. When the ability to perspire is impaired, temperature of the foot is raised and the risk is increased for infection, fissure development, and ulceration (Lazaro-Martinez et al., 2011).

Peripheral arterial disease affects 50% of patients with diabetic foot ulcers (Schaper et al., 2012a). Approximately 50% of patients with diabetes present with symptoms of PAD during routine assessment (Schaper et al., 2012b). Patients with diabetes and PAD develop neuropathic ulcers due to impaired circulation and ischemia. Ischemia of the lower limb reduces the availability of blood, oxygen, and other nutrients needed to facilitate healings if small wounds develop. In patients with diabetes and PAD, the distal peroneal and tibial arteries become narrowed and blood flow is impeded (Gibbons & Shaw, 2012).

Plantar Foot Pressure

Increased plantar foot pressure is a major predisposing factor implicated in development of neuropathic ulcers. In persons with diabetes, increased peak foot pressure typically presents in the forefoot and metatarsal heads. Pressure changes become difficult to detect due to loss of cutaneous sensation secondary to peripheral neuropathy, leading to altered gait and malformation of the feet. Reduced plantar tissue thickness under the metatarsal heads is another common finding in diabetes that contributes to increased foot pressure and soft tissue injury (Bowling, Reeves, & Boulton, 2011). Injury to the soft tissue of the foot, compounded by vascular complications of diabetes, leads to decreased perfusion and healing time of the lower extremity. This sequence of events eventually results in a sharp increase of infection and subsequent neuropathic ulceration (Bowling et al., 2011).



Foot Malformations

Malformations of the feet can cause increased foot pressure and ulceration. Malformations of the feet include hammer toe and Charcot Marie Tooth disease, a hereditary neuropathy that manifests as a rocker bottom foot; these lead to increased forefoot pressure and ulceration (O'Loughlin et al., 2010) (see Figure 1). See Figure 2 for general characteristics of the diabetic foot that contribute to neuropathic ulcer formation. Long-term diabetes also results in reduced ankle dorsiflexion, limiting the ability of the tibia to rotate over the foot during the mid-stance phase of walking. This gait abnormality interrupts the path of centered pressure under the foot, increasing peak pressure in the forefoot. The length of time for increased forefoot pressure during ambulation also raises peak pressures and contributes to neuropathic ulceration in the feet (Bowling et al., 2011).

Poorly Fitting Footwear

The use of poorly fitting footwear by patients with diabetes is the most common cause of foot ulceration; it elevates plantar foot pressures and increases mechanical stress on plantar and dorsal foot surfaces. Wearing inappropriate footwear exposes the patient to increased friction, irritation, and decreased foot protection (Rizzo et al., 2012). The combination of sensory loss secondary to neuropathy plus excessive pressure, friction, and irritation from inappropriate footwear leads to the formation of calluses, blisters, and ulcers. Effective offloading through proper footwear, worn as recommended, protects the foot and can reduce risk of ulcer recurrence by more than 50% (Waaijman et al., 2014). Nurses thus should stress the need for patients with diabetes to purchase properly fitted footwear based on several criteria: width of the shoebox (to allow toes to move freely); alleviation of excessive pressure; reduction of shock and shear; accommodation, stabilization, and support of deformities (such as hammer toe); and limited joint motion (to decrease friction and irritation).

Specialty options can include shoes with increased shoe depth (allowing extra volume to accommodate inserts and orthoses), external modifications (adding shocks), orthoses, and inserts to provide additional shock absorption. Custommade shoes can accommodate a person's unique foot design. Specialty footwear designs also are available to help patients off-load at-risk foot regions effectively (e.g., rocker-bottom outsoles, custommade insoles, shoe inserts). These footwear designs can reduce forefoot peak pressures 16%-52% compared to conventional footwear (Bowling et al., 2011; Cavanagh & Bus, 2010, 2011). However, current research regarding footwear recommendations is conflicting, possibly due to design flaws and intervention strategies that prevent adequate comparison. Thus, additional research is needed in the area of offloading pressure and use of foot insoles for prevention and healing of diabetic neuropathic ulcers.

Assessment of the Diabetic Foot

For all patients with diabetes who are at risk of neuropathic ulcer formation, foot assessment is critical for prevention and early detection of conditions that can contribute to ulceration (Jarrett, 2013).


Visual inspection of the foot should consist of daily examination for foot deformities, areas of redness, blisters, calluses, fissures, dry skin, and toenail appearance (thickness, ingrown toenails) (Sibbald et al., 2012). Patients with impaired vision also should have another person or health care provider inspect the feet. Patients with reduced visual capacity who lack a caregiver can rely on touch sensation and a magnifying glass to perform manual and visual inspection of the feet (Chin, Huang, & Hsu, 2013).

Pulse Evaluation

Nursing assessment of the feet of patients with diabetes should include evaluation for the presence and quality of the dorsalis pedis and posterior tibialis pulses; diminished pulses indicate high risk for ulceration. Absent pulses are indicative of circulatory impairment that predisposes the patient to amputation (Woo, Santos, & Gamba, 2013). Patients with DPN should have a health care provider assess the feet annually. Individuals with PAD should seek consultation every 3-6 months with a provider who specializes in vascular assessment (Chin et al., 2013; Sibbald et al., 2012).

Sensory Testing

Sensory testing is a critical component of monitoring the development and advancement of DPN. While nerve conduction studies are considered the gold standard for diagnosing peripheral neuropathy, the Semmes Weinstein monofilament test is considered clinically useful as a low-cost, noninvasive, easy-to-use assessment method (Craig, Strauss, Daniller, & Miller, 2014). Recommended current practice is to use a 5.07 gauge/10 g monofilament for performing sensory testing (see Figure 3). The patient is instructed to close the eyes for this procedure. The monofilament then is applied perpendicularly to each testing site until it bends (approximately 1 second). If the monofilament is felt, the patient is instructed to say "yes." Failure to sense the presence of the monofilament denotes lack of sensation. Five sites on each foot are recommended for sensory evaluation with the monofilaments (Feng, Schlosser, & Sumpio, 2009; Praxel, Ford, & Vanderboom, 2011).


Nursing Interventions for the Prevention of Neuropathic Ulcers

Improving Glycemic Control

Glycemic control appears to be the most important intervention for preventing neuropathic ulcers (ADA, 2015). In a randomized, controlled trial conducted by Ismail-Beigi and colleagues (2010), development of peripheral neuropathy in an intensive glycemic intervention group was reduced significantly compared to a standard treatment group. A Cochrane review by Callaghan, Little, Feldman, and Hughes (2012) examined the effects of enhanced glucose control on development of DPN. They found only two studies of type 1 diabetes used DPN as an outcome variable (Diabetes Control and Complications Trial Group, 1993, 1995). The results of a clinical trial indicated intensive glycemic control prevents DPN in patients with type 1 diabetes, potentially reducing the risk of ulceration. However, in type 2 diabetes, intensive glycemic control failed to achieve the same outcome in prevention of DPN (Callaghan et al., 2012).

Patient Education and Self-Care Practices

Providing patient education about prevention of foot ulceration and amputation in patients with diabetes is a common clinical practice (Dorresteijn, Kriegsman, Assendelft, & Valk, 2012). However, educational intervention has been found to influence patient behaviors for only a short time, and failed to impact long-term health behavior change that can influence adverse outcomes. Little evidence supports the efficacy of these practices in the prevention of neuropathic ulcers (Dorresteijn et al., 2012). Cisneros (2010) evaluated the effects of a 2-year foot care education program combined with use of protective footwear in preventing primary and recurrent neuropathic ulcers in 53 patients with diabetes and DPN. Incidence of ulceration in the intervention group was 38.1%, compared to 51.1% in the control group. Although the program decreased re-ulceration rates, the author concluded it was ineffective in the primary prevention of ulceration.

Nursing Implications

The prevention of neuropathic ulcers is a primary goal in the care of patients with diabetes. Nursing care should be directed toward persons with diabetes at highest risk for ulceration, but also include patients with a history of peripheral neuropathy and PAD, foot malformations such as high arches and clawing of the toes (see Figure 1), and persons with diabetes who experience poor glycemic control. Nurses should ask the patient about use of orthotics, insoles, or protective footwear. To monitor trends in glycemic control, nurses also should inquire about home monitoring and recording of glucose values, as well as monitoring of hemoglobin A,C (glycosylated hemoglobin) over time. Nursing assessment of distal peroneal and tibial arterial pulses, cutaneous sensation, and gait also are recommended as risk factors for ulceration or consequences of prolonged, uncontrolled diabetes. Examination of the diabetic foot by nurses should include visual inspection for foot deformities, calluses, fissures, redness or blisters, and ankle joint mobility.

Patient education, an important nursing responsibility, should include assessment of the effectiveness of patient teaching regarding common practices such as diabetic foot care (Dorresteijn et al., 2012). Reinforcement may be needed to ensure patient understanding and increase adherence to recommendations. Research has indicated patients with diabetes often fail to engage in consistent self-care of the feet (Chin & Huang, 2013).


Rigorous nursing assessment is needed for patients at high risk for neuropathic foot ulceration. Risk factors for ulceration need to be assessed and mitigated. Persons with diabetes need reinforcement of learning to ensure the best possible outcomes. A need also exists for maintaining optimal glycemic control to prevent DPN and reduce the risk of neuropathic ulcers while avoiding other adverse effects, such as hypoglycemia. Strategies that combine education, optimization of glycemic control, improved circulation and joint mobility, and decreased foot pressure are needed. Further research is needed to determine if a combination of strategies to prevent neuropathic ulcers in persons with diabetes may be most effective, but such measures have not been tested or validated for practice.


American Diabetes Association (ADA). (2003). Peripheral arterial disease in people with diabetes. Diabetes Care, 26(12), 3333-3341.

American Diabetes Association (ADA). (2015). Foot complications. Retrieved from

Baloh, R. (2013). Charcot foot. Retrieved from hmsn.html

Boulton, A.J. (2012). Diabetic neuropathy: Is pain God's greatest gift to mankind? Seminars in Vascular Surgery, 25(2), 6165. doi:10.1053/j.semvascsurg.2012.04. 009

Bowling, F.L., Reeves, N.D., & Boulton, A.J. (2011). Gait-related strategies for the prevention of plantar ulcer development in the high risk foot. Current Diabetes Reviews, 7(3), 159-163.

Callaghan, B.C., Little, A.A., Feldman, E.L., & Hughes, R.A. (2012). Enhanced glucose control for preventing and treating diabetic neuropathy. Cochrane Database of Systematic Reviews, 6, CD007543. doi:10.1002/14651858.CD007543.pub2

Cavanagh, P.R., & Bus, S.A. (2010). Off-loading the diabetic foot for ulcer prevention and healing. Journal of the American Podiatric Medical Association, 100(5), 360-368.

Cavanagh, P.R., & Bus, S.A. (2011). Off-loading the diabetic foot for ulcer prevention and healing. Plastic and Reconstructive Surgery, 127(Suppl. 1), 248S-256S. doi: 10.1097/PRS.0b013e3182024864

Centers for Disease Control and Prevention (CDC). (2011). National diabetes fact sheet: National estimates and general information on diabetes and prediabetes in the United States, 2011. Retrieved from http// pdf/ndfs.2011.pdf

Centers for Disease Control and Prevention (CDC). (2014). 2014 National diabetes statistics report: Estimates of diabetes and its burden in the United States. Retrieved from diabetes/pubs/statsreport14/nationaldiabetes-report-web.pdf

Chin, Y.F., & Huang, T.T. (2013). Development and validation of a diabetes foot self-care behavior scale. Journal of Nursing Research, 21(1), 19-25. doi: 10.1097/jnr. 0b013e3182828e59

Chin, Y.F., Huang, T.T., & Hsu, B.R. (2013). Impact of action cues, self-efficacy and perceived barriers on daily foot exam practice in type 2 diabetes mellitus patients with peripheral neuropathy. Journal of Clinical Nursing, 22(1-2), 6168. doi:10.1111/j.1365-2702.2012.042 91.x

Cisneros, L.L (2010). [Evaluation of a neuropathic ulcers prevention program for patients with diabetes]. Revista Brasileira Fisioterapia, 14(1), 31-37.

Craig, A.B., Strauss, M.B., Daniller, A., & Miller, S.S. (2014). Foot sensation testing in the patient with diabetes: Introduction of the quick & easy assessment tool. Wounds, 26(8), 221-231.

Diabetes Control and Complications Trial Research Group. (1993). The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New England Journal of Medicine, 329(14), 977-986. doi: 10.1056/nejm199309303291401

Diabetes Control and Complications Trial Research Group. (1995). Effect of intensive diabetes treatment on nerve conduction in the Diabetes Control and Complications Trial. Annals of Neurology, 38(6), 869-880. doi:10.1002/ana. 410380607

Dorresteijn, J.A., Kriegsman, D.M., Assendelft, W.J., & Valk, G.D. (2012). Patient education for preventing diabetic foot ulceration. Cochrane Database of Systematic Reviews, 10, CD001488. doi:10.1002/ 14651858.CD001488.pub4

Driver, V.R., Fabbi, M., Lavery, L.A., & Gibbons, G. (2010). The costs of diabetic foot: The economic case for the limb salvage team. Journal of Vascular Surgery, 52(3 Suppl.), 17S-22S. doi:10.1016/j.jvs. 2010.06.003

Feng, Y., Schlosser, F.J., & Sumpio, B.E. (2009). The Semmes Weinstein monofilament examination as a screening tool for diabetic peripheral neuropathy. Journal of Vascular Surgery, 50(3), 675-682. doi:10.1016/j.jvs.2009.05.017

Gibbons, G.W., & Shaw, P.M. (2012). Diabetic vascular disease: Characteristics of vascular disease unique to the diabetic patient. Seminars in Vascular Surgery, 25(2), 89-92. doi:10.1053/j.semvas csurg.2012.04.005

Gonzalez, J.S., Vileikyte, L., Ulbrecht, J.S., Rubin, R.R., Garrow, A.P., Delgado, C., ... Peyrot, M. (2010). Depression predicts first but not recurrent diabetic foot ulcers. Diabetologia, 53(10), 2241-2248. doi:10. 1007/S00125-010-1821-x

Howard, I.M. (2009). The prevention of foot ulceration in diabetic patients. Physical Medine and Rehabilitation Clinics of North America, 20(4), 595-609. doi: 10. 1016/j.pmr.2009.06.010

Ismail-Beigi, F., Craven, T., Banerji, M.A., Basile, J., Calles, J., Cohen, R.M., ... ACCORD trial group. (2010). Effect of intensive treatment of hyperglycemia on microvascular outcomes in type 2 diabetes: An analysis of the ACCORD randomised trial. Lancet, 376(9739), 419430. doi:10.1016/S014-6736(10)60576-4

Jarrett, L. (2013). Prevention and management of neuropathic diabetic foot ulcers. Nursing Standard, 28(7), 55-56. doi:10. 7748/ns2013.

Lavery, LA., LaFontaine, J., Higgins, K.R., Lanctot, D.R., & Constantinides, G. (2012). Shear-reducing insoles to prevent foot ulceration in high-risk diabetic patients. Advances in Skin and Wound Care, 25(11), 519-524. doi: 10.1097/ 01 .asw.0000422625.17407.93

Lazaro-Martinez, J.L., Aragon-Sanchez, F.J., Beneit-Montesinos, J.V., Gonzalez-Jurado, M.A., Garcia Morales, E., & Martinez Hernandez, D. (2011). Foot biomechanics in patients with diabetes mellitus: Doubts regarding the relationship between neuropathy, foot motion, and deformities. Journal of the American Podiatric Medical Association, 101(3), 208-214.

Ndip, A., Ebah, L., & Mbako, A. (2012). Neuropathic diabetic foot ulcers - evidence-to-practice. International Journal of General Medicine, 5,129-134. doi: 10. 2147/ijgm.s10328

Nerone, V.S., Springer, K.D., Woodruff, D.M., & Atway, S.A. (2013). Reamputation after minor foot amputation in diabetic patients: Risk factors leading to limb loss. Journal of Foot and Ankle Surgery, 52(2), 184-187. doi:10.1053Aj.jfas.2012. 11.015

O'Loughlin, A., McIntosh, C., Dinneen, S.F., & O'Brien, T. (2010). Review paper: Basic concepts to novel therapies: A review of the diabetic foot. International Journal of Lower Extremity Wounds, 9(2), 90-102. doi:10.1177/1534734610371600

Praxel, T.A., Ford, T.J., & Vanderboom, E.W. (2011). Improving the efficiency and effectiveness of performing the diabetic foot exam. American Journal of Medical Quality, 26(3), 193-199. doi:10.1177/ 1062860610383166

Rizzo, L., Tedeschi, A., Fallani, E., Coppelli, A., Vallini, V., lacopi, E., & Piaggesi, A. (2012). Custom-made orthesis and shoes in a structured follow-up program reduces the incidence of neuropathic ulcers in high-risk diabetic foot patients. International Journal of Lower Extremity Wounds, 11(1), 59-64. doi:10.1177/ 1534734612438729

Schaper, N., Andros, G., Apelqvist, J., Bakker, K., Lammer, J., Lepantalo, M., ... & Hinchcliffe, R.J. (2012a). Specific guidelines for the diagnosis and treatment of peripheral arterial disease in a patient with diabetes and ulceration of the foot 2001. Diabetes/Metabolism Research and Reviews, (Suppl. 1), 236-237. doi:10.1002/dmrr,2252

Schaper, N.C., Andros, G., Apelqvist, J., Bakker, K., Lammer, J., Lepantalo, M..... Hinchliffe, R.J. (2012b). Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot. Diabetes Metabolism Research and Reviews, 28(Suppl. 1), 218-224. doi: 10. 1002/dmrr.2255

Sibbald, R.G., Ayello, E.A., Alavi, A., Ostrow, B., Lowe, J., Botros, M., ... Smart, H. (2012). Screening for the high-risk diabetic foot: A 60-second tool. Advances in Skin and Wound Care, 25(10), 465-476. doi:10.1097/01. ASW.0000421460.2177 3.7b

Tesfaye, S., Vileikyte, L,, Rayman, G., Sindrup, S., Perkins, B., Baconja, M., ... Toronto Expert Panel on Diabetic Neuropathy. (2011). Painful diabetic peripheral neuropathy: Consensus recommendations on diagnosis, assessment and management. Diabetes/ Metabolism Research and Reviews, 27(7), 629-638. doi:10.1002/dmrr.1225

Waaijman, R., de Haart, M., Arts, M.L., Wever, D., Verlouw, A.J., Nollet, F., & Bus, S.A. (2014). Risk factors for plant foot ulcer recurrence in neuropathic diabetic patients. Diabetes Care, 37(6), 1697-1705. doi:10.2337/dc13-2470

Woo, K.Y., Santos, V., & Gamba, M. (2013). Understanding diabetic foot ulcers. Nursing 2013, 43(10), 36-42. doi:10. 1097/01.NURSE.0000434311.52768.1 d


Clayton, W., & Elasy, T.A. (2009). A review of the pathophysiology, classification, and treatment of foot ulcers in diabetic patients. Clinical Diabetes, 27(2), 52-58. doi:10.2337/diaclin.27.2.52

Muir, R.L. (2009). Peripheral arterial disease: Pathophysiology, risk factors, diagnosis, treatment, and prevention. Journal of Vascular Nursing, 27(2), 26-30. doi:10. 1016/j.jvn.2009.03.001

Prompers, L, Huijberts, M., Apelqvist, J., Jude, E., Piaggesi, A., Bakker, K., ... Schaper, N. (2007). High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia, 50(1), 18-25. doi:10.1007/s00125-006-0491-1


This continuing nursing educational (CNE) activity is designed for nurses and other health care professionals who are interested in preventing neuropathic ulcers in patients with diabetes. After studying the information presented in this article, the nurse will be able to:

1. Describe the etiology and risk factors for neuropathic ulcers.

2. Discuss assessment of the diabetic foot.

3. List nursing interventions for the prevention of neuropathic ulcers.

Note: The authors, editor, and education director reported no actual or potential conflict of interest in relation to this continuing nursing education article.

Sara K. Dominic, BSN, RN, is Doctoral Student, University of South Florida, Tampa, FL. Constance Visovsky PhD, RN, ACNP-BC, is Associate Dean, Student Affairs and Community Engagement, University of South Florida College of Nursing, Tampa, FL.

Janique Rice, MS, is Research Associate, University of South Florida College of Nursing, Tampa, FL.
COPYRIGHT 2015 Jannetti Publications, Inc.
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2015 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:CNE SERIES
Author:Dominic, Sara K.; Visovsky, Constance; Rice, Janique
Publication:MedSurg Nursing
Date:Sep 1, 2015
Previous Article:Thank you for your service!
Next Article:Outcomes achieved through implementation of interdisciplinary plans of care.

Terms of use | Privacy policy | Copyright © 2018 Farlex, Inc. | Feedback | For webmasters