Neuropathy - Appendix What is diabetic neuropathy ? What is a neuropathic ulcer and how do you treat it ? How often does the ulcer need to be treated ? Having an ulcer is a serious condition that can rapidly threaten the foot. Depending on the clinical situation, the doctor and health care team may need to see it everyday. Generally, once stabilized and the patient is doing the dressing everyday, it still needs to be seen and treated every week for removal of callus and for clinical assessment of its progress. Leaving it without local treatment for 3 weeks is usually too long. Can a neuropathic ulcer also have poor blood supply ? Undoubtedly. Many ulcers occur in people with both neuropathy and peripheral vascular disease. Therefore in the assessment of any neuropathic ulcer, it is necessary to determine if blood supply is impaired. This is done by palpating the foot pulses and if necessary by measuring ankle brachial index or toe pressure. When there is significant vascular impairment, such ulcer is called a neuro-ischaemic ulcer. In these cases, local treatment needs to be more cautious so that tissue is not damaged by excessive debridement. If the ulcer does not heal, then blood supply may need to be improved by angioplasty or surgery. When should a contact cast be applied ? Application of a contact cast should be considered when a plantar ulcer is not healing despite good wound care, adequate removal of callus, appropriate control of infection and presence of reasonable blood supply. This is usually after a few weeks of treatment. It should not be used if the ulcer is very deep (because the skin will heal over and a pocket is formed inside) or if the ulcer is very infected (because it will block drainage of infected material). What about walking exercise ? Walking is not a good exercise for anyone with a neuropathic ulcer because it slows down healing. Walking should be limited to essential activities. When is surgery indicated ? If an ulcer is very infected and cannot be controlled by antibiotic therapy, then surgical debridement may be necessary. If an ulcer does not heal or keeps recurring because of excessive pressure due to a local bone deformity, then it may be worthwhile correcting the deformity. A great deal of clinical judgement is required because surgery may shift the pressure point to somewhere else, causing another ulcer and perpetuating the problem.