| Diabetic Foot Ulcer Stages
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Diabetic Foot Ulcer Stages

Diabetic Foot Ulcer Stages

Diabetes mellitus is one of the most common diseases in the world, and the diabetic foot is considered as one of the most significant complications of diabetes, with an overall risk of developing a foot ulcer in diabetics being close to 25%. It causes severe morbidity in terms of disablement and leg amputation. Diabetes is the cause of almost 50% of all nontraumatic lower extremity amputations worldwide. Diabetic neuropathy and vasculopathy are the main underlying processes that lead to diabetic foot ulceration. Other contributing factors include trauma, biomechanical abnormalities, limited joint mobility, and infection.


Diabetic foot ulcers are classified as stages in order to have an appropriate treatment plan and follow up. Diabetic foot ulcers can be characterized as neuropathic, ischemic, or neuroischemic, depending on how complications such as peripheral neuropathy and arterial disease affect the etiology. There are several foot-ulcer classification methods that have been proposed but none has been universally accepted.


Wagner-Meggitt classification: based mainly on wound depth.

  • grade 0 – intact skin
  • grade 1 – superficial ulcer
  • grade 2 – deep ulcer to tendon, bone, or joint
  • grade 3 – deep ulcer with abscess or osteomyelitis
  • grade 4 – forefoot gangrene
  • grade 5 – whole foot gangrene.


University of Texas system: grades the ulcers by depth and then stages them by the presence or absence of infection and ischemia.

  • grade 0 – pre- or postulcerative site
  • grade 1 – superficial wounds through either the epidermis or the epidermis and dermis, but that do not penetrate to the tendon, capsule, or bone.
  • grade 2 – penetrate to tendon or capsule, but the bone and joints are not involved.
  • grade 3 – wounds penetrate to bone or into a joint.

Each wound grade is comprised of 4 stages:

  1. clean wounds
  2. nonischemic infected wounds
  3. ischemic wounds
  4. infected ischemic wounds.


The SAD classification: grades 5 ulcer features (size, depth, sepsis, arteriopathy, and denervation) on a 4-point scale (0–3).

International Working Group on the Diabetic Foot (PEDIS classification): grades the wound on a 5-feature basis: perfusion (arterial supply), extent (area), depth, infection, and sensation.

Infectious Diseases Society of America guidelines: based on it, infected diabetic foot is subclassified into the categories of mild (restricted involvement of only skin and subcutaneous tissues), moderate (more extensive or affecting deeper tissues), and severe (accompanied by systemic signs of infection or metabolic instability).


Wound size and depth are key and should be documented at the initial visit and at each subsequent visit. It is very important to inspect the tissue present at the base of the wound as it can provide a wealth of information regarding the vascularity and possible infection.


Plantar wounds (at the sole of the foot) are usually caused by repetitive, chronic, low-velocity trauma to a diabetic foot that has diminished sensory innervation due to neuropathy. Reducing repetitive trauma is essential to halt the process and promote proper healing.


Treatment approaches include debridement (mechanical or enzymatic), pressure offloading, meticulous wound care and preventing/treating infection.

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