Non-healing ulcer under the forefoot

Neuropathic: it sits at a pressure point, is painless, has surrounding callus, and the foot is warm and well perfused with palpable pulses. Ischaemic ulcers are painful, occur at the tips of toes or heel, have a punched-out edge and a cool, pulseless foot. Many are mixed, so always assess perfusion objectively with ABPI or toe pressures.

A positive probe-to-bone test, an ulcer larger than 2 cm² or deeper than 3 mm, and ESR above 70 all raise the probability. Plain radiographs are insensitive early; MRI is the imaging standard, and bone biopsy with culture gives the definitive diagnosis and guides antibiotic choice.

Offloading with a total contact cast or removable walker, sharp debridement of callus and necrotic tissue, infection control with culture-directed antibiotics, revascularisation if perfusion is inadequate, glycaemic and cardiovascular risk-factor control, and multidisciplinary foot-clinic follow-up.

Annual foot screening with monofilament and pulse assessment stratifies patients into low, moderate, high risk and active disease. Prevention rests on daily inspection, appropriate footwear and insoles, podiatry for callus, and rapid access to a specialist team when a new ulcer appears.