The diabetic foot: basic mechanisms of disease.

There remains vast truth in the statement "neuropathy causes diabetic foot pathology." However, if it were really that straightforward and if our understanding were complete, it is doubtful that ulceration and neuroarthropathy would be the public health problems that they are today. Diabetes is an insidious disease, and almost every component of the spectrum of hyperglycemic complications is active in creating foot lesions. These include dramatic alterations in all components of the peripheral nerves, the mechanical characteristics of bones and soft tissues, gait kinematics, the vasculature at both a microscopic and a macroscopic level, the immune system, and the fundamental processes of wound healing. Clinical treatments that address the biologic aspects of the problem without considering the mechanics, or vice versa, can sometimes be effective but fail to take advantage of all of the potential means to succeed. The greatest potential for future clinical advance lies in understanding and simultaneously addressing the many synergistic factors that cause both ulceration and neuroarthropathy.