Slow-Healing Foot Wounds in Diabetes: Why Circulation Must Be Checked

Dr Andrew Choong’s article on slow-healing foot wounds in diabetes was published by Medical Channel Asia on 14 October 2026. This post summarises the argument for patients and families in Singapore and explains what it means if you, or someone you care for, has a foot wound that is not closing.

A small sore on the foot of someone with diabetes is easy to dismiss. It often does not hurt, because diabetes dulls the nerves, so it is covered with a plaster and expected to close. When it does not, the usual explanations are sugar control, footwear or infection. All three matter. But the question that most often decides between healing and amputation is a different one: is enough blood reaching the foot?

Why does this matter so much in Singapore?

In 2016 the Ministry of Health declared a War on Diabetes. More than 450,000 Singaporeans were living with the condition, one in three of them undiagnosed, and the number was projected to approach one million by 2050. The complications fall hardest on the foot: according to the Ministry, nine in ten people who had a lower limb amputation in Singapore had diabetes, and in 2015 the country recorded about 180 diabetes-related major amputations per 100,000 adults with diabetes, three times the OECD average. The foot wound is where vascular surgery earns its place in that effort.

Why will a diabetic foot wound not close?

Healing is work, and work needs supply. Oxygen, nutrients, immune cells and antibiotics all reach a wound through the bloodstream. Diabetes narrows the arteries of the leg, often silently and often low down near the foot, so the wound has everything it needs except a blood supply. The Eurodiale study, which followed 1,229 patients with a new diabetic foot ulcer across ten European countries, found peripheral arterial disease in 49 per cent, and the 2023 international guideline puts the figure at approximately half. The classic warning sign, calf pain on walking, is often absent in diabetes because nerve damage hides it.

Does circulation really change the outcome?

Eurodiale showed that it does. A year after presentation, 84 per cent of ulcers in patients with good circulation had healed, against 69 per cent in those with arterial disease, whose rates of major amputation and death were three to four times higher. An ulcer is also rarely a one-off: a review in the New England Journal of Medicine estimates that up to a third of people with diabetes will develop a foot ulcer, and that once healed, around 40 per cent return within a year and two-thirds within five. That is why the diabetic foot deserves a circulation check, not just a dressing.

How should circulation be checked?

The international guideline recommends that every person with diabetes and a foot wound be assessed for arterial disease, whether or not they have symptoms, and that people with diabetes and no wound have their circulation checked every year. Feeling for the foot pulses is a reasonable first step but cannot rule arterial disease out. The reliable tests use a hand-held Doppler probe and a blood pressure cuff: the ankle-brachial index compares the pressure at the ankle with the arm, and the toe-brachial index does the same with a tiny cuff on the big toe, which matters because calcified ankle arteries in diabetes can give a falsely reassuring reading. Where the pressures are abnormal, the arteries are mapped with colour duplex ultrasound, a scan without radiation or injection. In a dedicated vascular ultrasound laboratory the pressures and the scan are done at the same visit.

What is the four-week rule?

The guideline offers a benchmark patients and families can use themselves. If a wound has not shrunk by at least half within four weeks of good standard care, the blood supply should be reassessed and a vascular specialist consulted about restoring it. Gangrene, spreading infection or a very low toe pressure should not wait four weeks; they need an urgent vascular opinion, because the timing of drainage and revascularisation decides what can be saved.

How is the blood supply restored?

A narrowed or blocked artery can usually be reopened from the inside. Through a needle puncture under local anaesthetic, a fine wire is passed across the blockage and the artery opened with a balloon, sometimes drug-coated, and occasionally a stent. There is no incision to heal, which matters when the problem is that wounds do not heal, and most people go home within a day. Bypass still has a place when the anatomy demands it, but for most patients a minimally invasive approach comes first. The leg angioplasty and stenting page explains the procedure in more detail.

What are the warning signs to act on?

Be seen promptly, not at the next routine visit, for: a break in the skin not clearly healing within two weeks; a wound pale, dusky or black at the edges; a foot colder or paler than the other; foot pain at night eased by hanging the leg down; and redness, swelling or discharge. Numbness is not reassurance. It is the reason the wound went unnoticed.

What should I ask my doctor?

Four questions cover most of it. Has my circulation been measured, not just felt? What were my ankle and toe pressures? Has the wound shrunk by half since it was first measured? If not, who is looking at the blood supply?

“Sugar control, footwear and clean dressings are necessary, but not always sufficient. If Singapore is to win its war on diabetes at the level of the foot, circulation belongs in the conversation from the first visit, not the last.”
Dr Andrew Choong, Medical Channel Asia, 14 October 2026

Read the full article: Slow-Healing Foot Wounds in Diabetes: Why Circulation Belongs in the Conversation (Medical Channel Asia, 14 October 2026). Other media features are collected on the In the Media page, and Dr Choong’s short video on diabetes, arteries and foot care covers the same ground.

Preparing for a vascular review

If you have diabetes and a foot wound that has not clearly improved within two weeks, or has not halved in size within four, a vascular review can establish whether the arteries are the reason. The diabetic foot wound care page explains how the foot is assessed, the peripheral arterial disease page covers the underlying condition, and the vascular ultrasound page describes the pressure tests and duplex scan done at the first visit. Patients travelling from the region can read how to arrange a review on the international patients page. To make an appointment, use the contact page.

Obesity and the Circulation: Why Vascular Surgeons Want Earlier Treatment

Dr Andrew Choong was one of the experts quoted in a Medical Channel Asia feature, Obesity: The Missing Link in Singapore’s Heart Health Strategy, published on 29 September 2025. This post, added to the blog in October 2026 so that the feature sits in the media archive, summarises the vascular side of the argument.

Every day in Singapore, around 22 lives are lost to cardiovascular disease, and the feature opens with the projection that this could nearly triple by 2050. Age and genetics play their part, but one of the largest and least treated contributors is obesity. The article brings together a cardiologist’s view of what excess weight does to the heart and a vascular surgeon’s view of what it does to the rest of the circulation.

What does a vascular surgeon see?

The arteries and veins outside the heart are where the consequences of obesity, high blood pressure, diabetes and high cholesterol eventually show. Dr Choong’s point in the feature is about timing: by the time most patients reach a vascular clinic, the damage has already been done. Legs are already swollen with venous disease, arteries are already hardened by peripheral arterial disease, and the kidneys may already be failing. “The tragedy is not just the disease, but the delay,” he says. “We are intervening too late.”

Why does obesity matter for the arteries and veins?

Fat stored around the abdomen and internal organs is metabolically active. As the cardiologist quoted in the feature explains, it drives inflammation, insulin resistance, abnormal blood lipids and high blood pressure, and all four accelerate the narrowing and stiffening of arteries. The same process that causes a heart attack in the coronary arteries causes a stroke in the carotid arteries, claudication and non-healing wounds in the leg arteries, and weakening of the aortic wall that can lead to an aneurysm. Excess weight also raises pressure in the leg veins and is one of the recognised risk factors for deep vein thrombosis.

What is the argument for earlier treatment?

The feature argues that obesity should be recognised as a chronic, relapsing medical condition rather than a personal failing, and treated with the same structure as high blood pressure or diabetes: early screening of at-risk groups, a proper medical and metabolic assessment, and sustained support with nutrition, physical activity and, where a doctor considers it appropriate, medical therapy. The aim, in Dr Choong’s words, is “lifelong cardiovascular health and freedom from disease”, so that fewer people reach the stage of bypasses, dialysis or amputations.

“In vascular medicine, we never wait for a stroke before treating high blood pressure, and we never wait for a heart attack before lowering cholesterol. Obesity should be no different.”
Dr Andrew Choong, Medical Channel Asia, 29 September 2025

What does this mean for you?

If you carry extra weight and also have high blood pressure, diabetes or high cholesterol, the arteries in your legs and neck are under the same strain as the arteries of the heart, and they can be checked without any radiation or injection. A duplex ultrasound scan shows whether the leg and carotid arteries are narrowing and whether the leg veins are working properly, long before symptoms force the issue. Warning signs that should not wait include calf pain on walking that eases with rest, a foot wound that is slow to heal, a swollen or painful leg, and any brief episode of weakness, numbness or loss of vision, which can be a warning stroke.

Read the full feature: Obesity: The Missing Link in Singapore’s Heart Health Strategy (Medical Channel Asia, 29 September 2025). Other media features are collected on the In the Media page.

Preparing for a vascular review

A vascular review looks at the whole circulation outside the heart: the carotid arteries, the aorta, the leg arteries and the leg veins. The peripheral arterial disease page explains how poor leg circulation is assessed, the aortic awareness page covers who should be screened for an aneurysm, and the vascular ultrasound page describes the scan itself. To make an appointment, use the contact page.