These should include neurological, vascular, laboratory and radiological investigations as described in Chapter 1.

Fig. 4.4 This deep sinus has a slit-shaped aperture.

While it is not necessary to X-ray every stage 3 foot with a presenting ulcer, it may be advisable to do so in the following circumstances:

• When the history suggests that the patient may have trodden on a foreign body

• When the ulcer probes to bone, clinically suggesting osteomyelitis

• If there are clinical signs of infection

• When there is unexplained pain or swelling which may be related to neuropathic fracture or Charcot's osteoarthropathy

• When the ulcer has been present for longer than 1 month.

Radiological studies of diabetic feet have revealed a high prevalence of fractures in neuropathic patients and most of these had not been previously diagnosed.

Having completed the history, examination and investigations, it is possible to make a firm diagnosis of ulceration either in the neuropathic foot or the neuroischaemic foot. The characteristic features are described in Table 4.1.

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