Diabetic neuropathic forefoot and heel ulcers: management, clinical presentation and outcomes

The two most common sites for diabetic neuropathic foot ulcers are the forefoot and the heel. Each site has special characteristics that determines its course. The aim of this study is to compare clinical presentation, management and outcome of diabetic neuropathic forefoot ulcers to diabetic neuropathic heel ulcers.

This was a prospective cross-sectional comparative study carried in Jabir Abu Eliz Diabetic Centre (JADC), Khartoum, Sudan. A hundred patients with neuropathic diabetic ulcer were included, half were forefoot ulcers and the other half were hindfoot ulcers, two patients were lost on follow-up from each group. Neuropathy was graded using 10g monofilament nylon. Patients with vascular ischaemia, ankle brachial index pressure (ABPI) <0.9 and >1.1 were excluded. Other patient's data included demographic, foot and ulcer characteristics, comorbidities and outcomes. Foot ulcers were categorised according to Wagner classification, site and size of ulcer and presence of infection. Comorbidities evaluated included hypertension, ischaemic heart disease and renal impairment. All patients received standard wound care and regular follow-up.

The age of the studied patients was 54.3 ± 11 years (mean ± standard deviation (SD 11)) and 52.9 ± 11 years for forefoot and heel ulcer respectively. The mean duration of diabetes was 12.4 ± 6 years for forefoot ulcers and 13.3 ± 7 years for heel ulcer. The mean duration of foot ulcer was 21 and 26 days for forefoot and heel respectively. Forefoot ulcers healed within 12 week in 45% of patients and by 20 weeks in 63%, while 35% of heel ulcers healed by 12 weeks and 54% healed by 20 weeks (p=0.058). Based on Wagner classification, healing was best in class 1 among both forefoot and heel ulcers, 22.4% and 12.2% respectively (p=0.003 for forefoot and 0.002 for heel). First and second metatarsal heads were the common site of forefoot ulcer. Heel ulcers >3cm dimension had longer duration of healing compared to forefoot ulcers at both 12 and 20 weeks (p<0.02).

Healing in diabetic neuropathic forefoot ulcer was better than heel ulcer, though not reaching statistically significant value. Wagner class 1 had the best healing among both ulcers and a heel ulcer >3cm had a significantly longer healing time.

The authors have no conflict of interest to declare.