Diabetic foot: Which one comes first, the ulcer or the contracture?

Abstract

Diabetic foot is among the most common complications of patients with diabetes. One of the known causes of foot ulceration is ankle equinus, which increases the pressure on the plantar surface during ambulation. Conversely, equinus contracture can be caused by a complicated wound, and it may be due to prolonged immobilization. In this paper, we reviewed the pathogenesis of both conditions and their clinical considerations. Poor glycemic control in patients with diabetes may result in angiopathy and neuropathy as an underlying condition. An ulcer can be precipitated by an injury, improper foot care, or increased biomechanical loading as seen in elevated plantar pressure following equinus contracture. Equinus contracture may be a direct effect of hyperglycemia or can arise in combination with another pathway, for example, involving the activation of transforming growth factor β. Static positioning resulting from any prior foot wound may develop fibrotic changes leading to contracture. Wound healing promoting factors can also result in overhealing outcomes such as hypertrophic scarring and fibrosis. The body’s repair mechanism during the healing cascade activates repair cells and myofibroblasts, which also serve as the main producers and organizers of the extracellular matrix. Considering this intricate pathogenesis, appropriate interventions are essential for breaking the vicious cycle that may disturb wound healing.

Analysis of Clinical Profiles, Deformities, and Plantar Pressure Patterns in Diabetic Foot Syndrome

“…Despite the huge progresses in clinical and biomechanical research and relevant technology [21,[33][34][35][36][37], deeper knowledge, more evidence and general validity, and a larger consensus are needed to effectively model as many risk factors as possible, and to predict the many alterations observed in patients, both in the foot structure and function [4][5][6][7][8][9][10]12]. Weight-bearing CT parameters in three patients with lesions: % of parameters outside the 95% confidence interval of each parameter, for the DNT1 (7 patients) and the DNNT1 (8 patients) subgroups.…”

Diabetic Foot: The Role of Fasciae, a Narrative Review

“…The forefoot stress could be further increased by the presence of hammer toe and claw toe [ 9 ]. In the last stage, it is difficult to trace a precise causal determination: for example, if the contracture or the ulceration came first [ 10 ]. In this vicious circle the continuity between the calf and plantar regions through fasciae could be useful to better address the treatment.…”

“…From a molecular point of view, the synthesis of protein in the muscle is decreased from 6 h after immobilization. In the first 24 h there is the shortening of the muscle fibers and 24 h later the perimysium begins to be infiltrated by collagen [ 10 ].…”

The Role of Early Revascularization and Biomarkers in the Management of Diabetic Foot Ulcers: A Single Center Experience

“…As such, DFU represents a significant global medical, social and economic problem. It is defined as a structural or functional alteration of the foot that may manifest as ulcers, osteomyelitis, or gangrene, as a result of the interaction of different factors, induced by sustained hyperglycemia and previous traumatic causes [ 1 , 2 ].…”