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FEATURE	NEUROPATHIC	NEUROISCHEMIC	ISCHEMIC
SENSATION	SENSORY LOSS	DEGREE OF SENSORY LOSS	PAIN
CALLUS/NECROSIS	PRESENT	MINIMAL CALLUS, PRONE TO NECROSIS	NECROSIS COMMON
WOUND BED	Pink and granulating, surrounded by callus	Poor granulation	Pale and sloughy with poor granulation
FOOT TEMPERATURE	Warm with bounding	Cool with absent pulses	Cool with absent pulses
OTHER	Dry skin and fissuring	Risk of infection	Delayed healing
TYPICAL LOCATION	Weight-bearing areas of the foot, such as metatarsal heads, the heel, and over the dorsum of clawed toes	Margins of the foot and toes	Nail edges and between the toes and lateral borders of the foot
PREVALENCE	35%	50%	15%

PERIPHERAL NEUROPATHIES

Peripheral neuropathy is damage to nerves of the peripheral nervous system, which may be caused either by diseases of or trauma to the nerve or the side-effects of systemic illness.

Diabetic peripheral neuropathy is a precipitating factor in almost 90% of diabetic foot ulcers.

Chronically high blood glucose levels damage the nerves, including the sensory, motor and autonomic nerves.

It also damages the immune system and impairs the body's ability to fight infection.

Sensory Neuropathy

Sensory neuropath affects the nerves that carry messages from the skin, bones and muscles to the brain.

Sensory neuropathy or damage to the sensory nerves of a diabetic patient causes loss of heat, cold, or pain sensations in the feet.

It is the most common form of neuropathy, mainly occurs in nerves in the feet and legs, but can also occur in the arms and hands.

Sensory neuropathy can also cause abnormal sensations and pain in some patients.

Even major pain sensations such as a cut or foot sore, a burn from hot water, or exposure to extreme cold may go unnoticed because of this lack of sensation increasing the risk of infection and poor healing.

Autonomic Neuropathy

Autonomic dysfunction causes decreased sweating resulting in dry skin, cracking, callus formation and ulceration making the skin vulnerable to infections.

It also increases the peripheral blood flow that leads to a warm foot.

Damage to the nerves can lead to dryness of the skin. Sweating is essential for skin moisture balance and without it the skin dries out and cracks. Moisturizing creams and regular professional foot care should be advised.

Figure 3: Callus tissue in DFU Patients

Motor Neuropathy

Motor neuropathy causes muscle weakness and loss of reflexes, especially in the region of the ankle.

This may change the way a person stands / walks leading to foot abnormalities and deformities such as bunions, hammertoes, and charcot foot.

Motor neuropathy plays an important role in the pathway of diabetic foot ulcers since they contribute to abnormal pressures in the plantar area of the foot predisposing it to frequent ulceration.

Figure 4: Motor Neuropathy

Charcot Foot

It is also referred as Charcot Neuroarthropathy (CN), Osteoarthropathy, Charcot neuropathic osteoarthropathy, or neuropathic arthropathy

CN is a condition affecting the bones, joints and soft tissues of the foot and ankle.

The early inflammatory acute condition may lead to varying degrees and patterns of bone destruction, subluxation, dislocation, and deformity.

In the chronic stage, the arch falls and the foot develops a 'rocker-bottom' appearance.

The condition of all these signs and symptoms is sometimes called the 'Charcot foot syndrome'.

Figure 5: Clinical Presentation of Charcot Foot

Peripheral Arterial Disease (PAD)

Diabetes damages the blood vessels by causing inflammation and atherosclerosis or hardening of the arteries.

Narrowing of the arteries causes ischemia due to restricted blood circulation reducing the availability of oxygen, glucose, and critical nutrients to the body tissues.

This lack of blood supply leads to failure of the natural body defence resulting in an increased risk of infection.

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