Leg and foot ulcers are categorized primarily as venous, arterial, or neuropathic (diabetic) — a classification that determines treatment completely. Misidentifying an arterial ulcer as venous and applying compression therapy can cause catastrophic limb-threatening ischemia. Accurate clinical differentiation is one of the most important diagnostic skills in podiatric medicine.

Venous Ulcers: Chronic Venous Hypertension Pathology

Venous ulcers result from chronic venous hypertension — elevated venous pressure from deep venous thrombosis (DVT) sequelae, venous valvular incompetence, or venous obstruction that damages the microvasculature and interstitium of the lower leg. Venous hypertension causes plasma protein leakage into the interstitium, hemosiderin deposition (producing the characteristic brown staining of the gaiter zone skin), lipodermatosclerosis (fibrosclerotic hardening and hyperpigmentation of the medial lower leg skin), and ultimately ulceration through skin fragility. Classic features: location at the medial gaiter zone (medial malleolus and distal medial lower leg), shallow wound with irregular borders, moist wound bed with fibrinous slough and granulation tissue, surrounding hemosiderin staining and lipodermatosclerosis, edema in the affected leg, relatively painless (a key distinction from arterial ulcers), and associated varicosities or post-thrombotic skin changes. Venous Doppler ultrasound confirms venous reflux and prior DVT. Treatment: compression therapy (the cornerstone — graduated 30–40 mmHg compression accelerates healing by 50–70% in compliant patients), wound dressings matched to exudate level, and leg elevation. Compression is contraindicated when ABI < 0.7 (arterial insufficiency).

Arterial Ulcers: Ischemic Tissue Loss

Arterial ulcers result from insufficient arterial perfusion — the tissue cannot meet its metabolic demands, and ischemic necrosis develops at the most vulnerable locations. Classic features: location at the distal toes, digital tips, between the toes (toe web spaces), or over bony prominences (lateral malleolus, fifth metatarsal base, heel), well-defined “punched out” wound edges with a pale, necrotic, or eschar-covered wound base that lacks granulation tissue, exquisitely painful (worse at night and with leg elevation — hence the “rest pain” that forces patients to sleep with the leg dangling), absent or diminished pedal pulses, cool foot temperature, dependent rubor, pallor with elevation, and thin atrophic skin with hair loss. ABI is diagnostic: < 0.5 indicates severe ischemia. Arterial ulcer treatment begins with vascular surgical referral — revascularization (bypass or endovascular angioplasty/stenting) is the only treatment that produces reliable healing by restoring perfusion. Wound care manages the ulcer surface while awaiting revascularization. Compression is absolutely contraindicated. Dr. Biernacki at Balance Foot & Ankle performs ABI testing and wound type classification at the first visit, ensuring each wound type receives the correct treatment pathway. Call (810) 206-1402.

When to See a Podiatrist

Many foot conditions can be managed conservatively at home, but some require professional evaluation. See a podiatrist promptly if you experience:

• Pain that persists for more than 2 weeks despite rest
• Swelling, redness, or warmth that isn’t improving
• Numbness, tingling, or burning in the feet
• A wound or sore that is not healing within 2 weeks
• Any foot concern if you have diabetes or poor circulation
• Nail changes that suggest fungal infection or other problems

At Balance Foot & Ankle, our three board-certified podiatrists — Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin — provide comprehensive foot and ankle care at our Howell and Bloomfield Township offices. Most insurance plans are accepted.

Dr. Tom Biernacki, DPM

Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.