Patients with diabetes who have an associated peripheral neuropathy may be unware of any trauma to the feet , injuries when they occur may be slow to heal because of impairment of the circulation . Secondary infection is always a risk and the presence of bacteria in open wounds inhibits healing . Also as a result of the neuropathy , the toes may become retracted so that the weight is thrown on the metatarsal head , consequently a common site of ulceration is under the first metatarso-phalyngeal joint , but ulcer may occur over any other bony prominence such as the big toe or the malleoli . Diabetic ulcers are usually painless and deep with punched out appearance ,progression of such an ulcer may lead to penetration of an underlying joint ,with exposure of the tendons and joints . Infection is likely to follow , with a chronic suppurative arthritis . Ischemic ulcers of the leg may also occur as a result of atherosclerosis and impaired circulation to the limb this may be seen in diabetics especially if they have noticed problems of intermittent claudication with pain in the limb on exercise or elevation . Such ulcers also have a punched out appearance with shiny, white or bluish surrounding skin , peripheral pulses may be reduced or absent
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