When traumatic injury occurs, the process of wound healing relies on a complex interplay between various body systems (cellular, immune, hematologic and metabolic processes). These complex processes can only occur when there is adequate circulation to the area of injury.

Circulation problems can inhibit the ability of the body to heal an established wound, and in some circumstances, circulation problems can be the primary cause of skin breakdown (ulcer).

Peripheral arterial disease (“PAD”) refers to a condition where plaque accumulates within the wall of an artery. Plaque accumulation within an arterial wall is conceptually analogous to a pipe getting “clogged up”. Narrowings and blockages created by the plaque make it difficult for oxygen-rich blood to flow to the lower portions of the legs and feet. Oxygen is a key ingredient for wound healing.

Severe peripheral arterial disease can dramatically compromise the flow of oxygenated blood to the feet and toes. In this situation, it is possible for skin breakdown (ulcers) to occur on the feet or toes, simply because there is inadequate oxygenated blood getting to these areas. This situation is often referred to as “critical limb ischemia.”


Skin ulcers caused by arterial problems typically occur on the toes (and/or feet), however, arterial problems can contribute to wounds/ulcers located anywhere on the leg.

Skin ulcers caused by vein problems (“venous-stasis” ulcers) typically occur just above the ankle area, but can also be located anywhere on the lower leg.

Symptom severity is surprisingly disparate for patients with leg ulcers.  Some patients have leg wounds/ulcers that are quite painful, yet other patients have significant size leg wounds/ulcers that are minimally symptomatic.

Regardless of symptom severity, anyone with spontaneous skin breakdown on their toe(s), foot or leg (or wound that has not healed within a few weeks of onset) merits evaluation by a vascular specialist or wound-care expert.

Diagnostic Workup

The diagnostic workup of a non-healing wound (or leg ulcer) is initially guided by clinical presentation and physical examination findings.

A detailed assessment of vascular problems can be established using a variety of painless, non-invasive, office-based tests. These office-based tests use a combination of ultrasound (duplex ultrasound) and blood-pressure cuffs to evaluate blood-flow abnormalities.

In some circumstances, additional diagnostic imaging (including X-rays, CT scans or MRI) may be necessary to rule out underlying infection, or further evaluate the blood flow in the arterial or venous systems.


In circumstances where plaque accumulation has resulted in significant reduction of arterial blood flow to the leg(s), there may be options to have procedures done to improve circulation and facilitate wound/ulcer healing.

For most patients with venous leg ulcers, initial therapy often consists of compression bandages and leg elevation to help control the leg swelling.

For patients with leg swelling secondary to venous insufficiency who are intolerant of compression bandages, there may be an option of using pneumatic “edema pumps” to help gently massage the excess fluid from the leg(s).

In circumstances where structural vein problems are confirmed the underlying abnormality can often be fixed using minimally invasive (outpatient) procedures.

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