Foot Ulcers

What are Foot Ulcers?

Foot ulcers are wounds, or open sores, that will not heal or those that keep recurring on the foot or feet. The three most common types of foot ulcers include venous stasis, diabetic (neurotrophic), and arterial (ischemic ulcers)

Ulcers are typically defined by the appearance of the ulcer, the ulcer location, and the way the borders and surrounding skin of the ulcer look.

At Yale Vascular Surgery, we offer the widest range of treatment and management options for various types of foot ulcers. In addition to being well-versed with the traditional or classic techniques and surgeries, many additional procedures offered by our innovative surgeons are at the leading edge of vascular surgery. Our multidisciplinary vascular team works collectively to create personalized treatment plans that provide the best options for each patient, reflecting his or her specific condition and individual needs.

Venous Stasis Ulcers 

Damaged valves or blocked veins may cause the blood in the veins to back up and pool in the vein. Sometimes, the blood leaks out of the vein and into the surrounding tissue, which can cause the tissue to breakdown, forming an ulcer. 

Diabetic (Neurotrophic) Ulcers 

Nerve damage (neuropathy) in the feet can result in a loss of foot sensation. Therefore, when a person with neuropathy has a callous, injury, or crack on their foot, they cannot feel it. The injury can go unnoticed and untreated, leading to infection or an ulcer. 

Arterial (Ischemic) Ulcers

An arterial ulcer can result from any interruption of arterial blood supply to skin tissue on the feet. Wounds need oxygenated blood to heal. If that does not happen, the wound can worsen and become gangrenous. 

Symptoms of Foot Ulcers

Symptoms of a foot ulcer vary with the type of ulcer. 

Venous stasis ulcers appear red and may be covered with yellow, fibrous tissue. Some may have a green or yellow discharge. The borders of this type of ulcer are irregular. If there is significant swelling, the skin surrounding the ulcer may look shiny and tight. 

Diabetic (neurotrophic) ulcers are usually located on pressure point on the bottom of the feet, though they can occur anywhere on the foot. They may appear pink, red, brown, or black. The borders of the ulcer appear punched out, and the surrounding skin is often calloused. 

Arterial (ischemic ulcers) tend to occur on the heels, tips of toes, between the toes where the toes rub against one another, or anywhere the bones may protrude and rub against bed sheets, socks, or shoes. They often occur in the nail bed if the toenail cuts into the skin. Arterial ulcers may have a yellow, brown, grey, or black appearance. They usually do not bleed. The borders appear punched out and there may be swelling around the ulcer. 

If you have any of the above symptoms, or if you notice redness, swelling, bleeding, and blisters, please contact your doctor right away, especially if you have a known risk factor that can lead to foot ulcers.

Risk Factors of Foot Ulcers

If left untreated, ulcers may lead to gangrene and amputation, which is why it is important to understand if you have risk factors that may lead to an ulcer. At Yale Vascular Surgery, we emphasize patient education and risk factor reduction and management. 

Factors that may increase your chance of developing a foot ulcer by type include: 

Venous Stasis Ulcers

Venous stasis ulcers are common in patients who have a history of venous insufficiency, leg swelling, varicose veins, or a history of blood clots in either the superficial or the deep veins of the legs. 

Diabetic (Neurotrophic) Ulcers

As their name suggests, diabetic ulcers generally occur in people who have diabetes, although anyone who has reduced sensation in the feet are at risk. Neuropathy (nerve damage) and peripheral artery disease often occur together in people who have diabetes, and both conditions can increase the chance of developing an ulcer. 

Arterial (Ischemic) Ulcers

Arterial (Ischemic) Ulcers can occur in the nail bed if the toenail cuts into the skin or if the patient has had recent aggressive toenail trimming or an ingrown toenail removed. 

Risk factors for all ulcer types include: 
  •  Peripheral Artery Disease 
  •  Diabetes Mellitus 
  •  Microvascular Disease 
  •  Obesity 
  •  Physical Inactivity 
  •  Family History of Vascular Disease 
  •  High Cholesterol 
  •  Hyperlipidemia 
  •  Hypercoagulable States 
  •  Hypertension 
  •  Atrial Fibrillation 
  •  Arterial Embolism 
  •  Mitral Stenosis 
  •  Endocarditis 
  •  Patent Foramen Ovale 
  •  Prosthetic Heart Valve 
  •  Post-Surgical Clotting 
  •  Radiation Necrosis 
  •  Trauma 
  •  Certain Medications 
  •  Cancer 
It is important to understand that having one or more of the risk factors does not mean that you will develop an ulcer. The list should be used only as a guideline. 

Ways that you can manage your risk factors to prevent ulcers or to prevent an ulcer from getting worse include:
  • Stop smoking
  • Manage blood pressure
  • Control blood cholesterol and triglyceride levels (through diet and medications as prescribed) 
  • Limit sodium intake
  • Manage diabetes 
  • Exercise (talk to your doctor for an exercise plan that is right for you)
  • If you are obese or overweight, develop and follow a plan to lose weight

Diagnosing Foot Ulcers

Ulcers can be diagnosed during a physical evaluation and by asking about your health history. There are some things your doctor will look for, such as: 
  • How deep the ulcer is
  • Whether there is an infection present
  • Whether that infection has spread to the fat tissue or bone 
  • Whether you have any foot abnormalities, circulatory problems, or neuropathy that will interfere with healing
In order to determine blood circulation, your doctor may measure blood pressures and waveforms in different parts of your leg using specialized cuffs. They may also use a duplex Doppler ultrasound to show how well the blood is moving through your lower legs. A duplex Doppler ultrasound is a non-invasive test that uses sound waves to estimate the speed and direction of blood as it flows through the blood vessels. 

Other non-invasive imaging scans, such as an MRI or CT scan, may also be used to assess the ulcer so that an effective treatment plan can be created. 

Treatment for Foot Ulcers

It is important to have foot ulcers treated immediately, because they can worsen in a short period of time. If left untreated, an ulcer can quickly become an abscess and infection can spread to the underlying fatty tissue and even the bone. These types of infections can easily lead to gangrene.

At Yale Vascular Surgery, our team includes nationally renowned surgeons who are dedicated to helping patients affected by foot ulcers. They will help determine the best-possible comprehensive treatment by using the latest technology and compassionate care. 
Should you require surgery, our surgeons will review your surgical plan with you, in detail, so that you know what to expect before, during, and after the surgery.

The goal of treatment for foot ulcers is to relieve pain and to speed recovery. Non-surgical treatment of ulcers may include: 
  • Antibiotics, if an infection is present
  • Antiplatelet or anticlotting medications to prevent a blood clot
  • Topical wound care therapies
  • Compression stockings or bandages to minimize swelling
At home, patients can:
  • Lift legs above the level of the heart as often as possible. For example, when lying down, prop the legs up with pillows
  • Be certain to use compression stockings or bandages, removing them only when bathing or sleeping 
  • Walk daily if possible
  • Gently cleanse affected area daily with a mild soap, and thoroughly dry the area

Venous Ulcer Treatment

Venous ulcers are treated mostly with compression and dressing. Dressings may include: 
  • Moist to moist dressings
  • Hydrogels/hydrocolloids
  • Alginate dressings
  • Collagen wound dressings
  • Debriding agents
  • Antimicrobial dressings
  • Composite dressings
  • Synthetic skin substitutes

Arterial Ulcer Treatment

Arterial ulcer treatments have the goal of providing protection to the skin’s surface, prevention of new ulcers, removing any contact irritation to the existing ulcer, and monitoring symptoms of infection. Endovascular or bypass surgery may be used to restore circulation to the affected foot. 

Endovascular procedures
Endovascular procedures include methods to open the artery. The most common endovascular techniques are angioplasty (Endovascular Angioplasty), which uses a balloon or other method to open the blocked artery, or the placement of a stent (Endovascular Stent Repair), which is a tiny, expandable metal coil placed inside an artery to keep the artery open.

Bypass 
For more extensive blockages, bypass surgery may be required.

In bypass surgery, a Y-shaped tube made of synthetic fabric, called a graft, is attached to the aorta above the blockage to create a detour around the narrowed or blocked sections of the artery. 

Diabetic (Neurotrophic) Ulcer Treatment

Treatment for diabetic ulcers includes avoiding pressure and weight-bearing on the affected leg and regular removal of affected tissue. Special shoes or orthotic devices may also be necessary.