Foot examination should be carried out as described in the introduction. The ulcer should then be examined noting:

Fig. 4.1 An ischaemic ulcer on the margin of the foot with a halo of erythema.

• Appearance of the ulcer and surrounding tissues

• Associated swelling

• Tenderness

The implications of these are discussed below. Site

Ulcers on the plantar surface are usually neuropathic and ulcers on the margins of the foot are usually neuroischaemic. However ulcers can appear in other sites.

Interdigital ulcers can be caused by the toes being squeezed together in tight, ill-fitting shoes in both neuropathic and neuroischaemic feet.

Ulceration on the dorsal aspect of the toes is often associated with pressure from tight shoes in either class of foot.

Ulcers on the plantar aspect of the heel are usually caused by acute trauma, particularly treading on foreign bodies. Indeed, trauma can cause ulceration at any site in either class of foot.


Any break in the skin, however small, can lead to disaster. However, larger ulcers usually take longer to heal.

Appearance of the ulcer and surrounding tissues

The colour of the base of the ulcer is important. A pink, clean, glistening ulcer bed is healthy. Variation in the colour of the ulcer bed may be significant: for example, a wound bed which is largely pink but has an area of grey discolouration often overlies a sinus. Many poorly perfused ischaemic wound beds are grey or yellow and sloughy. Moist green or yellow slough indicates infection and patients should be managed as described in Chapter 5.

Black tissue indicates necrosis and the foot should be regarded as at stage 5 and managed accordingly.

Neuropathic ulcers are usually surrounded by callus, which is often white and rubbery because it is macerated by discharge from the ulcer. The neuropathic ulcer may be almost completely covered over by callus.

Neuroischaemic ulcers may be surrounded by a small halo of thin, glassy callus.

Diffuse redness of the surrounding tissues may indicate infection in both neuropathic and neuroischaemic feet, especially if this is associated with swelling and purulent

Fig. 4.2 This healing ulcer is surrounded by an area of shiny new pink and white epithelium.

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