Emphasizing a Proactive Multidisciplinary Approach To The Combination Of Neuropathic Ulcers And Peripheral Arterial Disease

David G. Armstrong DPM MD PhD

Joe Mills, MD, and I, along with many of our colleagues, have been struck with how our population has changed but our methods (and language) have not. We discussed this previously in a dendrogram (cluster analysis) from a study I co-authored with Lavery and Peters in 2008. (see http://www.ncbi.nlm.nih.gov/pubmed/18593392 ).

In this study, we theorized that identifying unique causal pathways and pivotal factors associated with developing foot ulcers may lead to earlier intervention and complications that are less frequent and less severe.1 We focused on 87 patients with 103 existing or recently healed ulcers. Our study identified 24 pathways with the seven most common unique pathways accounting for 64.1 percent of the cases. Cluster analysis revealed four consistent, dominant clusters: neuropathy, deformity, callus and elevated peak pressure; peripheral vascular disease; penetrating trauma; and Ill-fitting shoe gear.

Please note that component causes of ulcers (neuropathy, deformity, repetitive stress) form one cluster, one tributary if you will. The other cluster is formed solely by peripheral arterial disease. For a long time — generations, in fact — these problems have been relatively separate. Therefore, care for them could be separate. Now, however, they have joined to create a torrent or a current of pathology. This is because, in the developed world, our neuropathic patients have now become neuroischemic. 

We cannot keep rowing separately. We have to join up lest we be swept away. Common language and even common teams really are the way forward. We are all in the same boat.


1. Lavery LA, Peters EJ, Armstrong DG. What are the most effective interventions in preventing diabetic foot ulcers? Int Wound J. 2008; 5(3):425-33.

This blog has been adapted with permission from a blog that previously appeared at http://www.diabeticfootonline.blogspot.com/2012/10/neuropathic-ulcers-an... .

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