First of all, with the presence of diabetic neuropathy, their occurs a wasting or weakening of the intrinsic muscles of the foot. These are the muscles that act to stabilize the digits and as the neuropathy progresses the digits will tend to contract and develop the hammertoe deformity. Secondly, as the neuropathy progresses, the patient lacks the ability for normal proprioception and as such they will begin to claw and grip the ground with their toes to assist with propulsion. The more they do this the tighter the tendons become and inevitably the hammertoe deformities occur. As a Finally, a grade IV ulceration, which again indicates the presence of significant vascular compromise and small vessel disease.
Ischemic ulcerations are usually distal on the foot and usually follow an end-artery pattern.
In the neuropathic patient these are perfectly asymptomatic, but in a person with normal sensation these are very very painful. This too takes into account numerous items. The patient s activity level, the general health status of the patient, the nutritional level. It s not just one factor to determine whether or not it is going to heal. But most important of all is the vascularity of the patient.