Prevention of New and Recurrent Foot Wounds

  • Michael B. Strauss, MD; Anna M. Tan, DPM; Lientra Q. Lu
  • Volume 07 - Issue 3

Part 2: Education

In Part 1 of this five-part series, we introduced the subject of the prevention of new and recurrent foot wounds and discussed and dispelled a number of misconceptions about foot wounds.¹ In this article we discuss the education aspects of the prevention  of foot wounds and offer information about “do’s” and “don’ts” to prevent them.

The value of proactive prevention of complications was conclusively demonstrated in the Diabetes Control and Complications Trial (DCCT) Research Group study.² The study showed that with optimal management of blood sugars through glucose monitoring and precise dosing of insulin, diabetic complications were reduced 50 to 75 percent as compared to the control group. Progression of neuropathy and ophthalmological angiopathy were the two elements monitored in the DCCT trial.

It is possible to reduce the occurrence of diabetic foot wounds to a similar extent when wound prevention strategies are employed.3 Prevention strategies start with patient education.

In no other aspect of medicine is the value of preventive medicine as tangible as in patients with diabetes in general, and in diabetics with foot problems in particular. In the USA, approximately one-third of diabetic treatment costs are spent on treating diabetic foot wounds. Education in the diabetic with foot problems is a “two-way street.” From one direction comes the advice from the patient’s physicians and associated care providers (Figure 1).

FIGURE 1. Physician advice and patient compliance can be a two-way street.

Legend: To be Successful in preventing new and recurrent foot wounds, the physician and other care providers must be on the same "wavelength" as the patient. This is achieved through education. 60% recurrence rates of foot ulcers when not moving in the same direction. 5,6

The terms foot wounds and diabetic foot ulcers (DFUs) need to be differentiated. Although common terminology for wounds in the feet of diabetics are reported as DFUs, we feel that this is not the most appropriate terminology. Foot ulcers suggest that they are superficial wounds that arise from shear stresses or pressure concentrations penetrating to only the subcutaneous tissue level. Wounds are a more generic term, can have many etiologies ranging from trauma to Charcot neuroarthropathy, and can involve deep tissues such as fascia, muscle, bone and joint.


The other direction is the patient’s responses and compliance with the advice. Education is the key to preventing the 60 percent reported recurrence rate of healed diabetic foot ulcers in patients with a previous wound.5, 6

Patient education starts with the primary care provider. This level of care providers includes physicians, nurse practitioners, physician assistants and diabetic nursing educators. Three education goals from the educators in this role need to be achieved (Figure 2). They include the following: 1) ascertaining patient compliance, 2) instructing patients in do’s and don’ts with respect to the foot, and 3) prescribing an appropriate activity level for the patient. The education objective for the patient with the potential for new or recurrent foot wounds is adherence to the recommendations of the primary care providers and the specialists who managed the wounds. The remainder of this part of our prevention of new and recurrent foot wounds series of articles will focus on the above three aspects of patient education.

FIGURE 2. Physician advice and patient compliance can be a two-way street.

FIGURE-2Legend: The three components of patient education to prevent new and recurrent foot wounds. The education process starts with the primary care providers and is "fine tuned" by the specialist such as the cardiologist or the foot surgeon.

The foot is particularly prone to developing wounds because of its location and anatomy. With it being the most distal portion of the human body, it has the furthest distance for blood to travel from the heart to it than any other body structure. The first signs of peripheral artery disease are usually noted in the foot.
The foot, a relatively small structure compared to the overall body mass, transfers the entire body weight to the supporting surface when standing and walking. Thus, there is a force-concentration effect resulting in the propensity for pressure buildups under bony structures and deformities. When they exceed the integrity of the overlying soft tissues, foot ulcerations develop.
Anatomy-wise the foot is filled with tendons, ligaments, bones, joint capsules and neurovascular structures with a dearth of soft tissues such as muscle mantles and subcutaneous tissues. This increases its vulnerability to injury.
Finally, neuropathies usually first manifest themselves in the feet with losses of sensation, muscle imbalances leading to contractures and deformities, autonomic nervous system dysfunction causing dryness of the skin, soft tissue atrophy, and loss of proprioception. These changes make the skin more vulnerable to ulceration than would happen with equivalent stresses in patients without these problems. The neurological effects are usually found in combination with each other such that pain over a deformity that is amendable to surgical correction before a wound develops is not felt. This results in the patient delaying medical care until odor or drainage indicates that something is wrong.

Risk Factors for the Development of Foot Wounds  

One of the first education considerations that primary care (PC) providers of diabetics need to be aware of is whether their patients have any of the risk factors for the development of foot wounds. The risk factors include deformity, peripheral artery disease, history of previous wound, previous amputation and neuropathy (Table 1).7,8  If one or more of these factors exists, the PC provider should inform patients of their increased risks for developing diabetic foot wounds. We have observed that the more risk factors present, the more likely wounds will occur. If any of the risk factors are present, it behooves the PC provider to not only discuss the significance of the risk factor with the patient but also inspect the feet. Other risk factors also need to be considered, including diabetes mellitus, obesity with or without the metabolic syndrome, smoking, malnutrition, immobility, and miscellaneous considerations such as infirmity, Alzheimer’s disease, skin and soft tissue atrophy, and residuals of a stroke (Table 2). If skin attenuation, preulcerative lesions, soft tissue atrophy or diseased toenails are observed, the patient should be referred to a foot specialist for management. For preventive medical aspects as well as the prewound stage, management includes skin and toenail care, selection of protective footwear and proactive surgeries. Each of these will be discussed in subsequent articles in this series.

TABLE 1. The five major risk factors for the development of extremity wounds



TABLE 2. Other risk factors for foot wounds


New or recurrent foot wounds may be from direct or indirect causes (Table 3).9 Direct causes rapidly lead to foot wound problems and include inappropriate footwear, accelerated level of activity, sudden structural changes in the foot, or malunited fractures. Indirect causes are due to repetitive stresses in patients who have propensities for developing wounds, including those with risk factors as well as venous stasis disease, abnormal weight-bearing mechanics from structural changes of the foot after surgery, loss of normal tissue elasticity from scar tissue, glycosylation of soft tissues, abnormal gait patterns secondary to neurological deficits, overloading especially associated with contralateral lower- limb problems, obesity and collagen vascular diseases.

TABLE 3. Direct and indirect causes of foot wounds


Quantifying Compliance in Patients with the Propensity to Develop Foot Wounds

The second education goal of the PC practitioner as well as the physician managing the patient’s wound care is to ascertain the patient’s compliance. Compliance is an indicator of how well the patient follows instructions and guides the provider for determining what wound dressing agents should be used and how often the patient needs to return for follow-up evaluations after a wound heals. We quantify compliance with a user-friendly 0- to 10-point (best possible) Goal Score generated by summating five assessments each graded from 2 points (best) to 0 points (worst) (Table 4). Even though the Goal Score has five assessments, with compliance being one of the five, information from the other assessments supplements the compliance determination and helps to make decisions about management and follow-up. For the Goal Score we grade compliance as “Satisfactory” (2 points), “Partial” (1 point) and “absent” (0 points). The 0- to 2-point assessment is determined by what compliance consideration is the most seriously violated.

TABLE 4. Goal Score

Note: The "Goal Score" is another useful tool to determine how successful and how intent the patient and the family are in healing a wound and avoiding a major amputation. Goal Scores greater than 4 points supports the decision to avoid lower limb amputation and do everything possible for wound salvage. This score coupled with the Wellness Score (Table 2) provides objectivity to recommned management of limb-threatening wounds.

When we graded five systemic elements and five wound- care elements reflecting compliance on 0- to 2-point (best) scales, the “splitter-type” data added no better information than the user-friendly “satisfactory,” “partial” or “absent” compliance determination from the Goal Score (Table 5).

How does compliance information aid in the education process? First, it helps in making decisions about treatment strategies, especially the protection/stabilization and wound dressing selection ones. If compliance is full, then weight- bearing and wound-care instructions are likely to be done without deviations. If compliance is poor, that is 0.5 or 0 on the 0- to 2-point compliance assessment, then casting (with windows for wound care) to protect and immobilize the wound and simplified, infrequent wound dressings utilized can be done periodically in a clinic or by a home health-care service. This may not be the optimal care for the patient's wound but is the necessary one for the patient's compliance grade.

Strategies for managing the problem wound have been discussed in the first author’s preceding articles in Wound Care and Hyperbaric Medicine.10-18 The five strategies include appropriate management of the wound base, stabilization and protection of the wound site, optimal medical management, proper selection of wound dressing agents, and attention to wound perfusion-oxygenation needs.
Usually quick observations make it possible to determine the compliance grade. For example, a morbidly obese patient would be graded low in compliance. Inspection of the feet for skin and toenail care instantaneously provides information as to compliance. Dry scaly skin found at return visits after the patient (or their aids) have been instructed in foot hygiene and lubrication indicates some compliance, while the presence of plaques and scales justifies a 0-point grade of this compliance consideration.

Second, the compliance assessment helps in making decisions about how frequently the patient with the healed wound needs to return for follow-up visits to ensure no new or recurrent wounds develop (Figure 3). For patients with a 0.5 or 0 grade, the follow-up visits need to be frequent, perhaps once or twice a month. For the middle group with partial compliance (1 point on the compliance assessment), visits can be spaced out to quarterly. Finally, in the fully compliant patient, yearly follow-up visits or returns on an as-needed basis are appropriate. At return visits the feet need to be examined for structural changes, recurrence of callus, attenuated skin sites as well as whether or not adjustments or replacement of protective footwear is needed.

FIGURE 3. Compliance as a guide to determining the need for follow-up evaluations of the healed foot wound

FIGURE-3Legend: The compliance assessment of the Goal Score is a useful guide for gauging the frequency of return visits after a wound heals. This is especially true for patients who have systemic or previous wound care considerations regarding compliance, See Table 5 for specifics of systemic and wound considerations for measuring compliance.

Instructing the Patient in the Do’s and Don’ts for Preventing New or Recurrent Foot Wounds

There are a number of recommendations that patients who have the propensity to develop foot wounds need to follow. Most are easy to follow and take only a moment’s time to do. They are as important to foot-wound prevention as blood- glucose monitoring and insulin dosage are for preventing complications of diabetes. It is important for the PC providers and other caregivers who help with management of the wound to communicate the instructions to prevent new or recurrent foot wounds. Although it is important that the patient is aware of all of the do’s and don’ts of foot-wound prevention, some of them have more pertinence than others. This is where knowing the patient is more important than knowing the disease so that at follow-up visits only the crucial do’s and don’ts are reinforced. Likewise, the patient’s compliance as discussed above will determine how often the do’s and don’ts need to be reinforced at follow-ups.

There are several levels of responsibility for doing this. The PC provider is the first level of the hierarchy in educating the patient about the do’s and don’ts. Next comes the wound-care specialists and surgeons who directly deal/dealt with the wound problem. The diabetic nurse educator can bridge the gap between the PC and wound-management providers to focus on the pertinent do’s and don’ts for the particular patient. Finally, but probably at the top of the list, is the patient and/or their care assistants who have the 24/7 responsibility for preventing new or recurrent foot wounds.

1. Be aware of the risk factors that are predispositions to foot wounds. These include deformities, peripheral artery disease, history of a previous wound, prior amputation, and/or neuropathy (Table 1).

Rationale: Self-awareness and self-reliance are fundamental to maintaining good health, and the prevention of foot wounds is no exception.

Remember: The time the patient spends with a physician or other health-care provider is almost infinitesimal compared to the time between visits. If the patient does not bring a wound problem or risk factor to the attention of the health-care provider, it will not likely be checked.

Most foot problems are remedial, and the sooner they are addressed, the easier they are to manage. Many problems when first recognized can be managed in the office with protective footwear and/or simple surgeries.

2. Make your primary-care provider aware of your goals to keep your feet healthy and your desire for immediate referral to a foot specialist if and/or when needed.

Rationale: In the majority of cases, management of foot problems that have the potential for becoming wounds can be done before serious problems arise.

Remember: With time constraints and the need for efficiency, the foot exam or questions about the healthiness of the feet may be overlooked unless concerns are specifically expressed to the primary-care physician.

3. Those patients with one or more risk factors need to inspect each foot and healed wound site daily after removing shoes.

Rationale: The earlier a wound or potential wound is recognized, the easier it is to manage and the faster it can be resolved.

Remember: Use good lighting, wear glasses if needed for viewing small objects, and use a mirror if there are problems with agility to see the bottoms of the feet. Check for pressure areas (signaled by erythema), irritated areas with superficial abrasion of the skin, calluses, dry skin, scaling, plaques, cracks and fissures in the skin, blisters, corns, and deformities.

4. Inspect socks daily for stains; always wear white socks if risk factors for foot wounds are present.

Rationale: With sensory neuropathy, the first sign of an impending wound problem, namely pain, may not be appreciated. Stains as occurring with blister formation of a wound may be the first clue that something is wrong. Almost any stain will be noted on white socks.

Remember: Stains on socks are a sign that the skin integrity of the foot has been disrupted. To disregard this sign is tantamount to denial that a problem exists. The cause of the stain should always be identified and the problem addressed immediately.

5. Practice good foot skin hygiene daily.

Rationale: The skin is the first “line of defense” for the prevention of foot wounds. The healthier the skin is, the more it can tolerate insults that lead to wounds. Simple skin cleansing and lubrication measures are a first step to ensure the health of the skin of the feet.

Remember: Attention to foot and leg skin care is as important for preventing skin complications of these structures as blood-sugar monitoring and management is to preventing complications of diabetes (Figure 4).

In addition, the quality and consistency of foot care is a measure of patient compliance.

FIGURE 4. Inadequate skin and toenail care

Legend: Above photos of patients who obviously have not practiced the "do's" of skin and toenail care. Initiation of care should be done by the primary care providers and taught to the patient. The less compliant the patient, the more frequent return visits are needed to reinforce this and do the interventions required to prevent new and recurrent foot wounds.

6. Perform appropriate toenail care.

Rationale: Toenail problems are commonly associated with diabetic foot wounds. This will be discussed further in Part 3 of this series. As in skin care, toenail management can be used as another measure of compliance (Figure 4).

Remember: Only the simplest of toenail care measures should be done by the patients themselves, especially if the toenails are diseased, neuropathy is present, agility problems (insufficient flexibility to position toes in a safe position to trim) exist and/or vision is impaired.

7. Wear appropriate foot wear to accommodate your foot problems.

Rationale: The more severe the foot deformities, the more specialized the protective footwear requirements are. A future article in this series will further discuss this subject.

Remember: Appropriate prescriptions for footwear require knowledge of the underlying problem — i.e., the biomechanics. Hence the more complicated the problem, the greater the need for the footwear prescription to be written by wound-care providers with expertise in foot problems.

8. Check shoes and orthotics periodically for signs of wear or poor fit.

Rationale: Footwear and orthotics lose their stabilizing ability with activity and use. In addition, the shape of the patient’s foot may change with time and progression of the problem as is frequently observed in patients with Charcot neuroarthropathy. With loss of footwear protection and stabilization, recurrent or new wound problems, stress fractures and/or new deformities may arise.

Remember: The time the patient spends with a PC provider or other health-care provider is very little compared to the time between visits. Hence, the patient and/or his/her attendants are usually the first to recognize these problems and bring them to the attention of the primary-care providers and foot specialists.

9. Walking and other exercise activities should be selected based on the patient's capacity to do them safely as determined by the PC providers but often in collaboration with specialists such orthopaedists (for bone and muscle functional considerations) and cardiologists (for heart matters).

Rationale: Exercise has many benefits such as improving cardiovascular fitness, enhancing stamina, complementing weight reduction, augmenting mobility, preventing osteoporosis, and stimulating angiogenesis.

Remember: Exercise regimens need to be tailored to the capabilities of the patient and will be discussed further in the next section of this article.

10. Optimize body weight and body mass index.

Rationale: Obesity complicates almost every medical problem. With respect to foot problems, each additional pound of weight multiplies stresses across the foot by a factor of three or more when walking (Figure 5).

FIGURE 5. The adverse effects of weight on the foot


Legend: The foot and ankles are remarkable structures. They transmit the entire weight of the body with standing and walking through the smallest portions of the lower extremities. Because of force effects (mass x acceleration), each pound of body weight increases the forces between the foot and the underlying support surfaces by threefols factor.

Wound care can be very challenging in the morbidly obese patient. Casts and orthotics may be difficult, if not impossible, to fit. Non-weight bearing on the injured extremity even for transfers may be impossible.

Remember: Weight reduction is a challenging problem. The PC physician should initiate diet programs with help from the clinical nutritionist. Minimally invasive surgical techniques add a new dimension for surgical management of obesity.

Ten Important Patient Don’ts for Preventing Foot Wounds

Many of the don’ts are a specific consequence of neuropathies and failure to recognize the warning signs of new or impending injuries. All patients who have risk factors for wounds and/or have had a serious wound, especially in the feet, need to heed the following don’ts with respect to foot wound prevention.

1. Don't walk barefoot.

Comment: Sharp objects or rough surfaces can cause wounds in the feet. Foreign objects such as needles may penetrate the skin of the foot. The injury may go unnoticed until drainage, odor or both are noted. Sensory neuropathy may disguise the pain.

Factors that interfere with infection control — such as diabetes, peripheral artery disease, collagen vascular diseases, atrophic skin and deformities — may allow infections to develop, whereas a wound would not occur in people without these problems.

2. Don't soak the feet in hot water.

Comment: Although foot hygiene starts with cleansing, two factors make the patient with risk factors for wounds particularly susceptible to burn injuries of the feet. First, a sensory neuropathy may prevent patients from recognizing the magnitude of the heat stress and fail to warn them to cease the exposure.

Second, heat exposures, which would not ordinarily cause burns, may lead to burns in patients with peripheral artery disease. These patients do not have the ability to dissipate heat at the same rate (via blood circulation) as patients with normal perfusion.

3. Don't use heat on the feet.

Comment: This don’t is a corollary to the preceding one. Strong admonitions need to be given to patients who use heating pads or hot-water bottles to warm their feet because of poor circulation. If these devices are used, patients should be instructed to select only low temperature settings or use warm (not hot) water temperatures. For added safety, if electrical devices are used, they should have timer switches to limit the durations of exposure.

4. Don't use chemicals or sharp objects to trim calluses.

Comment: These items may cause wounds. Because they are not sterile, there is the possibility for infections to develop if the skin integrity is broken. Chemicals harsh enough to eradicate calluses will cause damage to the adjacent skin should they come in contact with it.

Furthermore, with impaired agility and/or vision, difficulties in adequately trimming the callus (or applying the chemical debriding agent) may occur. Too little trimming will not be adequate to offload the underlying deformity. Too much trimming will penetrate the skin surface and lead to bleeding and possible infection.

5. Don't trim the edge portions of toenails that are embedded into the skin.

Comment: The embedded ends (medial and lateral portions of the distal margins) of toenails, especially the hallux nails, thicken, accumulate debris and grow into the underlying soft tissues. This becomes a precursor for ingrown toenails and paronychia (infection of the toenail margins from the edges of the toenail penetrating the skin).

Expertise in toenail care and appropriate instruments are required to manage debris at the toenail margins as well as dystrophic, dysmorphic, thickened, and fungus- infected nails.

6. Don’t assume a new pair of shoes, even from a footwear prescription, will fit properly.

Comment: Even though protective footwear may be specially prescribed, it may not always fit perfectly. In addition, a period of adjustment to new shoes should always be recommended in those patients who have neuropathy in their feet. In such situations, the new shoes should be worn for only a few minutes initially; then the feet should be inspected for pressure areas, blisters and erythema.

Typically, there is a “break-in” period for new shoes in which the materials stretch and accommodate to the wearers’ feet. This is why a “go slow” admonition should always be given to each patient who gets a prescription for new protective footwear to not discard the old shoes until the new shoes are fully adjusted.

In about half the patients with new protective footwear prescriptions, subsequent adjustments to the footwear are required. This is not a sign of improper prescriptions, but rather it reflects the challenges that the patient’s feet present.

7. Don’t assume a new pair of shoes, even from a footwear prescription, will fit properly.

Comment: Toenail polish, lacquer or acrylic generates an impermeable barrier over the toenail. The polish not only may hide underlying toenail problems that require special care but also may prevent air from getting to the toenail surface. The drying effects of air may prevent toenail infections since fungus infections thrive in moist environments.

8. Don’t wear constricting bands around the feet and ankles or rings on the toes.

Comment: These devices may interfere with circulation. More commonly, the constricting bands interfere with venous and lymphatic return, causing swelling distal to the constriction. Consequences may lead to pressure areas with shoe wear leading to blisters and ulcerations. If the swelling is severe enough, it may also interfere with the arterial blood supply and can lead to gangrenous changes, especially in the patient who already has poor circulation.

Indentations from the elastic bands at the proximal margins of socks suggest the bands are too tight. Corrective measures include wearing stockings with uniform compression or cutting the elastic bands at the top of the socks. If indentions are observed in sock wear, it is an indication to use elastic support hose.

Socks that are too tight over the toe areas may cause pressure on the toenails. This can contribute to the development in ingrown toenails.

9. Don’t wear inappropriate shoes.

Comment: Shoes with pointed toes, as considered fashionable by some, narrow the forefeet. Acutely this can lead to pressure sores. With extended use, deformities such as hallux valgus and bunions are prone to develop.

TABLE 5. Supplemental compliance measures

Systemic Components to Measure Compliance Local Wound Components to Measure Compliance
1. Glycemic control 1. Dressing change
2. Exercise/Activity 2. Off-loading
3. Diet (Obesity) 3. Skin/Toenail care
4. Smoking History 4. Edema control
5. Medication Adherence 5. Follow-up exams

Likewise, high-heel shoes should be avoided. These concentrate pressures in the forefeet, especially the metatarsal heads, and narrow the toes into a spear shape with weight bearing. Consequences are the development of bunions and hallux valgus, calluses under the metatarsal heads, pressure atrophy of the metatarsal fat pads, hyperextension of the metatarsophalangeals joints of the toes, proximal retraction of the toes on the dorsum of the forefoot, pressure forces on the toenails, and shortening the Achilles tendon mechanism.

10. Don’t smoke.

Comment: The harmful effects of smoking tobacco in general, and for wound healing in particular, have become well publicized. More than 4,000 harmful substances have been identified in tobacco smoke. Nicotine causes narrowing of the arteries. Other substances such as carbon monoxide and tars cause damage to blood vessels.

Studies show that tobacco smokers have double the complication rates from surgeries as do nonsmokers. Many surgeons, especially for elective cosmetic procedures, refuse to operate on patients who smoke tobacco.19

Since smoking tobacco interferes with oxygen delivery to tissues, it is important for patients with risk factors for foot wounds, especially those with peripheral artery disease, to not smoke.

Choosing Appropriate Activities to Prevent New and Recurrent Foot Wounds

The third component of patient education is the selection of appropriate activities for the patient’s level of function. It is essential to consider the patient’s capacity for activities when prescribing recommendations about appropriate activities for patients who have risk factors for foot wounds. Activity level can be placed on a spectrum from unlimited, such as in world-class athletes, to none, as in a bed-ridden patient who requires total assistance for all activities of daily living. The Wellness Score is another tool to quickly assess the functional capacity of the patient and make recommendations for activity (Table 6). The ambulation assessment of the Wellness Score provides a benchmark for patients’ activities and is graded on the 0- to 2-point scale like other assessments. A score of 2 points indicates the patient is capable of doing community ambulation; 1 point, household ambulation; and 0 points, no ambulation. Half points are used if intermediate between two levels, and a half point is subtracted if aids are required.

TABLE 6. Wellness Score

Criteria 2 Points 1 Point 0 Points
ADLs Full Partial Helped for all
Ambulation Community Household None
Comorbidities Normal Impaired Decompensated
Tobacco/Immunosuppressors None Past use Current
Neuro Function Normal Impaired Decompensated


  • Subtract 1/2 point if mixed or between 2 point grades
  • Subtract 1/2 point if  aids needed for ambulation (e.g. canes, crutches, walkers, wheelchair, scooters, or motorized wheelchairs
  • Do not consider neurological deficits in the comorbidities assessment since neuro-function is a separate assessment in itself
  • Malnutrition and obesity should be included in the comorbidities assessment

Other components of the Wellness Score provide supplemental information for the activity “prescription.” For example, patients with cardiac comorbidities may need to limit activities that do not overly stress their heart. Patients with paraplegia may be community ambulators with a wheelchair. Because of the need for the wheelchair, their ambulation assessment grade would be 1.5 points rather than 2 points. Patients with foot deformities and/or profound sensory neuropathies should be advised against doing running activities for exercise.


The question is raised: Should diabetics with peripheral sensory neuropathy run marathons? We feel it is inadvisable because of the prolonged repetitive stresses to the insensate foot that could lead to foot ulcers. The possible exception is the “proven” athlete who runs regularly, uses optimal footwear for running, has a deformity-free foot and has not had a history of previous foot wounds. In such cases, short races up to 10 kilometers are probably OK. We feel it would be ill-advised, however, for a diabetic with total sensory neuropathy to run longer-distance marathons.

Naturally, there is more to exercise and activity than ambulation level alone. Patients with risk factors for foot wounds and/or low assessment grades on other components of the Wellness Score who are capable of exercising should be encouraged to do so. The three cardinal components of an exercise program are muscle stretching and joint ranges of motion, resistance exercise to increase strength, and cardiovascular conditioning (Table 7). Exercise recommendation should be made by the PC providers and in collaboration with the foot specialist if a foot problem was managed previously by the specialist. Ideally, the initial activity program should be supervised by a physical therapist. The patients and their assistants should then be instructed in the procedures they can continue after the supervised course of therapy is completed.

TABLE 7. The three cardinal components of an exercise program


Finally, patient education should conclude with rehabilitation expectations. After prolonged periods of immobilization as often required with wound healing in patients with comorbidities, mobility may be slow to return. The older the patient and the lower the Wellness Score (Table 6), the slower the progress is likely to be.

Physiological age, however, is more important in making recommendations for activity. When providing directions for rehabilitation of a patient with a foot wound, the physiological age becomes the important determinant in what the patient can and should do. Even though progress may be slow, patients should be encouraged to have a positive attitude regarding regaining functional activity.

It takes about a year for a patient with a below-knee amputation to plateau with respect to functional recovery. Information such as this can be used to reassure the patient discouraged with his/her slow rehabilitation progress after the healing of a foot wound. This is part of the educational process for the healed foot wound patient.


Chronological age is the age based on the patient’s birthdate. Physiological age reflects a patient’s activity level, cognitive function, and health as compared with a person of a different age. Consequently, the physiological age may be much lower than the chronological as an 80-year-old who runs marathons. Conversely, it may be much higher as in a 50-year-old with coronary artery disease requiring supplemental oxygen to remain comfortable.



Patient education is fundamental for the prevention of new and recurrent foot wounds. There is probably no other medical situation in which there is such a close relationship between recognizing the potential for a foot wound  problem and being able to educate how to prevent it from happening. With such objectivity, the 15-minute visit with the care provider every couple of weeks during healing of the foot wound and at longer intervals (depending on the patient’s compliance) after the wound is healed can be a very effective use of time when the three components of this article are used as a guideline. The components are recognition and mitigation of risk factors, do’s and don’ts with respect to protecting the foot from wounds, and selecting appropriate activity. This is epitomized by the quotation, “To educate is wonderful, to use what is learned is sublime.” The real success stories in problem wound management and prevention are those in which the patients, their families and/or their care assistants apply what has been taught to them.

Fifteen minutes of contact with a physician every two weeks represents 0.074 percent of the total time in this interval, whereas a visit once every three months represents only 0.012 percent of the time.
This information emphasizes the crucial nature of what happens between medical checks is largely the determining factor for success or failure to prevent new and recurrent foot wounds.
The 15-minute visit needs to be focused to ensure the patient and his/her caregivers are doing the right thing to prevent foot wounds and if not, then be instructed in what they should do.


The “common sense” approach to patient education is strongly recommended. Rather than just telling patients and their family or assistants what to do and what not to do, it is better to explain the reasons for the advice. The starting point for this explanation are the rationale, things to remember, and comments portions of the do’s and don’ts recommendations. Certainly not all patients will understand and remember this information. The comprehension assessment (i.e., satisfactory, partial or absent) of the Goal Score quantifies how well the patient understands this information and guides the PC providers and wound-care specialists how to direct their advice during return visits.

Sublimity (of outstanding and/or exalted worth and value) in terms of wound prevention may be equated to the state in which the patient and his/her assistant understand and fully comply with the education given to them by their medical and surgical care providers.



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About the Authors


MICHAEL STRAUSS, M.D., an orthopaedic surgeon, is the retired medical director of the Hyperbaric Medicine Program at Long Beach Memorial Medical Center in Long Beach, California. He continues to be clinically active in the program and focuses his orthopaedic surgical practice on evaluation, management and prevention of challenging wounds. Dr. Strauss is a clinical professor of orthopaedic surgery at the University of California, Irvine, and the orthopaedic consultant for the Prevention- Amputation Veterans Everywhere (PAVE) Problem Wound Clinic at the VA Medical Center in Long Beach. He is well known to readers of WCHM from his multiple articles related to wounds and diving medicine published in previous editions of the journal. In addition, he has authored two highly acclaimed texts, Diving Science and MasterMinding Wounds. Dr. Strauss is actively studying the reliability and validity of the innovative, user-friendly Long Beach Wound Score, for which he already has authored a number of publications.



ANNA M. TAN, DPM, is the chief resident of podiatric medicine and surgery at Long Beach Memorial Medical Center. She graduated cum laude from the University of Southern California in 2006 and received the Dean’s Award for her undergraduate research on netrin-1, a protein involved in axonal guidance. Subsequently, she attended the California School of Podiatric Medicine at Samuel Merritt University in Oakland, California, receiving her doctor of podiatric medicine degree in 2014. Dr. Tan has special interests in surgical management of problem wounds and limb salvage. In her spare time, she enjoys Bikram yoga, cooking and traveling.


LIENTRA LU is a research assistant at the VA Medical Center in Long Beach, California, under the guidance of Dr. Ian Gordon, a vascular surgeon, and Dr. Michael Strauss, the first author of this paper. She is also an administrative assistant in the accounting department of the Southern California Institute for Research and Education (SCIRE). She received a bachelor of science degree in chemical biology at the University of California, Berkeley, in 2015 and subsequently has taken medically related courses at the University of California, Los Angeles. Miss Lu is helping with diabetic foot and venous leg ulcer studies in addition to research on abdominal aortic aneurysms at the VA Medical Center while also serving as an assistant in patient care at the PAVE Clinic there. She also works with the American Red Cross in her other interest, disaster preparedness.





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