Management of Foot Sores Related to Peripheral Artery Disease (PAD)
Foot sores in PAD patients require comprehensive evaluation, prompt treatment, and specialized footwear to prevent amputation and reduce mortality risk. 1
Risk Assessment and Evaluation
High-Risk Factors for Foot Ulcers in PAD
- History of previous foot ulcers or amputation
- Charcot or other foot deformities
- Diabetes with poor glycemic control
- Chronic kidney disease (especially ESKD)
- Peripheral neuropathy with loss of protective sensation
- Corns or calluses (considered pre-ulcerous lesions)
- Ongoing smoking 1
Components of Comprehensive Foot Evaluation
- History: Previous ulcers, claudication, rest pain, revascularization procedures
- Physical examination: Look for:
- Signs of infection: local pain/tenderness, erythema, periwound edema, discharge, foul odor
- Pre-ulcerous lesions: dry cracked skin, calluses, corns
- Deformities: bunions, hammertoe, claw toe, flatfoot, high-arch foot, Charcot foot 1
Management Protocol
1. Immediate Interventions
- Foot inspection at every clinical visit with shoes and socks removed 1
- Prompt diagnosis and treatment of foot infection to avoid amputation 1
- Look for: pain, erythema, edema, discharge, foul odor, visible bone
- Systemic signs: fever, tachycardia, elevated WBC
2. Preventive Care
- Therapeutic footwear for high-risk patients 1
- Annual comprehensive foot evaluation to identify risk factors 1
- Referral to footcare specialist for ongoing preventive care 1
- Patient education on self-foot care:
- Daily inspection of feet
- Proper washing and drying
- Nail and skin care
- Avoiding barefoot walking
- Wearing appropriate footwear
- Protecting feet from temperature extremes 1
3. Treatment of Active Ulcers
- Debridement of necrotic tissue and surrounding callus 2
- Appropriate dressings to control exudate and maintain moist environment 2
- Offloading devices for plantar ulcers (total contact cast) 2
- Negative pressure wound therapy for post-operative wounds 2
4. Vascular Assessment and Intervention
- Evaluate perfusion: Ankle-brachial index (ABI), toe pressures, or transcutaneous oxygen pressure (TcPO2) 2
- ABI <0.9 suggests PAD; <0.5 indicates severe disease requiring revascularization
- Consider revascularization when:
- Ulcer not healing within 6 weeks despite optimal management
- Ankle pressure <50 mmHg or ABI <0.5 2
5. Interdisciplinary Care
- Prompt referral to interdisciplinary team for foot infection 1
- Team should include vascular specialists, podiatrists, and wound care specialists 2, 3
Monitoring and Follow-up
Frequency of Assessment
- Low risk: Annual foot screening
- Moderate risk: Every 3-6 months
- High risk: Every 1-3 months 1
Ongoing Care
- Regular assessment of healing progress
- Monitoring for complications (infection, worsening ischemia)
- Adjustment of therapy based on response 2
Prognosis and Outcomes
PAD with foot ulcers carries a 40% mortality rate at 5 years and is associated with anxiety, depression, and reduced quality of life. Proper management can achieve limb salvage rates of 80-85% and ulcer healing in >60% at 12 months 1, 2.
Common Pitfalls to Avoid
- Delayed recognition of infection: Diabetes and PAD may make infection presentation subtle
- Inadequate offloading: Failure to use appropriate devices to reduce pressure on ulcers
- Premature amputation: Consider amputation only after revascularization attempts have failed
- Overlooking self-care education: Patient education is essential for preventing recurrence
- Neglecting risk factor modification: Smoking cessation, diabetes control, and management of hypertension and dyslipidemia are crucial 1, 2
Remember that PAD patients with foot ulcers represent a high-risk population requiring vigilant care to prevent limb loss and reduce mortality risk.