Leg Ulcers (Ulcus Cruris): Wound Healing, Compression, and Podiatric Treatment Pathways

Underlying causes

The medical term for a leg ulcer (offenes Bein) is ulcus cruris. It refers to a deep tissue defect on the lower leg or foot that extends into the dermis or subcutaneous fatty tissue and shows no tendency to heal for at least four weeks. The causes of this condition are anatomical and physical in nature. In approximately 80 percent of all cases, chronic venous insufficiency (CVI) is the underlying cause. This is referred to as ulcus cruris venosum or a venous leg ulcer.

The veins of the lower leg transport deoxygenated blood back to the heart against gravity. Venous valves function as non-return valves, while the calf muscle pump exerts pressure on the vessels with every movement. If these valves no longer close completely due to connective tissue weakness, following deep vein thrombosis, or as a result of prolonged lack of movement, blood pools in the legs. Hydrostatic pressure in the capillary vessels increases continuously. Due to this elevated pressure, fluid, proteins, and red blood cells leak into the surrounding connective tissue.

The red blood cells break down in the tissue, releasing the blood pigment haemoglobin, which is degraded into haemosiderin. This leads to the typical brownish-grey skin discolouration. At the same time, tissue oedema formation prevents adequate transport of oxygen and nutrients to the skin cells. Microcirculation comes to a standstill locally. The tissue dies off, resulting in a venous ulcer.

In contrast stands ulcus cruris arteriosum (arterial leg ulcer), which accounts for around ten percent of cases. In this case, advanced peripheral arterial disease (PAD) is present. Narrowed or calcified arteries can no longer convey sufficient oxygenated blood to the periphery. Even slight pressure loads or minimal injuries cause tissue to become ischaemic and necrotic. Combined forms, known as ulcus cruris mixtum, unite venous congestion with reduced arterial blood flow and require particularly careful consideration of all therapeutic steps.

Typical signs

A leg ulcer usually announces itself long before the actual skin defect appears. In a venous ulcer, the skin on the lower third of the lower leg, typically above the medial malleolus (inner ankle), appears discoloured and hardened. Specialists refer to this as lipodermatosclerosis. The tissue feels doughy to board-like and firm. In addition, yellowish-white, scarred skin areas known as atrophie blanche appear. These zones are extremely painful and prone to injury.

The wound itself in a venous ulcer is usually shallow, irregular in shape, and frequently exudes large amounts of wound fluid (exudate). The wound bed is often covered with yellowish fibrin deposits. Despite the frequently considerable dimensions, pain typically diminishes when the leg is elevated, as the venous congestion pressure subsides.

An arterial ulcer presents quite differently. It develops primarily on the acral areas, such as the toes, the heel, or over bony prominences of the foot. The wound margins appear sharply punched out, as if cut with a scalpel. The wound bed is mostly dry, pale, or covered with black necrosis. Patients report unbearable, burning pain that worsens drastically when the leg is elevated. Often, the only relief for patients is hanging the foot out of bed.

An example case from podiatric practice illustrates the distinction: Mr M., aged 72, presented with a seemingly small blister on the outer aspect of the heel. The skin surrounding the blister was cool and pale, and peripheral foot pulses were not palpable. This was not a pressure ulcer caused solely by inappropriate footwear, but the initial manifestation of an arterial ulcer in previously undiagnosed peripheral arterial disease. Immediate referral to a vascular surgeon was decisive in saving the foot.

Causes in everyday life

The development of a leg ulcer is favoured and accelerated by numerous factors in daily life. One of the most common causes is long-term lack of physical activity. Anyone who sits or stands for many hours without sufficient movement due to occupation or age deactivates the muscle-joint pump in the ankle. The venous valves become permanently overloaded.

Foot deformities also play a critical role. Hallux valgus, hammer toes, or pronounced flat feet alter the rolling motion during walking. If the upper and lower ankle joints are no longer used through their full range of motion, the pumping efficiency of the calf muscles diminishes. The result is increased venous congestion extending into the finest capillaries of the sole of the foot.

Inappropriate footwear severely exacerbates these problems. Shoes that are too tight create pressure peaks on the toe joints, whereas shoes that are too loose or worn out offer no support and cause friction. When the skin barrier is compromised, a tiny blister is enough to initiate a vicious cycle of infection and chronic wound formation. Improper home foot care also poses significant dangers. Trimming nails with sharp instruments, forcefully removing calluses with razor blades, or applying aggressive corn plasters frequently leads to micro-trauma.

Among underlying conditions, diabetes mellitus and hypertension rank highest. Diabetic neuropathy deprives affected individuals of pain sensation. A pinching shoe or a small stone in the shoe goes completely unnoticed. The wound develops silently, while diabetic macro- and microvasculopathy severely impairs wound healing right from the outset.

When medical evaluation is necessary

A leg ulcer must never be self-treated. As soon as a skin lesion on the lower leg or foot shows no signs of healing after two weeks, a specialist examination is mandatory. Phlebologists, dermatologists, or vascular surgeons must clarify the exact cause.

Certain warning signs require immediate medical intervention:

• Rapidly increasing redness, warmth, and swelling around the wound, indicating erysipelas or phlegmon.
• Sudden, severe pain or rapid discolouration of the wound bed to black (necrosis).
• Fever, chills, or a deterioration in general well-being.
• Malodorous, foul smell or purulent discharge from the wound.
• Absence of foot pulses accompanied by cold, pale, or blue-mottled skin on the toes.

For example, compression therapy must never be initiated without a sound medical diagnosis regarding arterial circulation. In cases of undiagnosed advanced peripheral arterial disease, tightly applied compression can completely interrupt the remaining blood flow and lead to loss of the limb.

What podiatric treatment can achieve

Medical foot care within podology forms the interface between medical therapy, nursing services, and the patient. It serves prevention, the maintenance of an environment conducive to wound healing, and the offloading of damaged tissue structures. Treatment is always performed under the strictest hygiene standards in accordance with university guidelines. Information on our safety protocols can be found at /en/hygiene.

In the practice, the session begins with a thorough inspection of the feet and lower legs. The podiatrist assesses skin condition, checks the pulse status of the dorsalis pedis artery and posterior tibial artery, and evaluates pain sensitivity using a monofilament and tuning fork. The actual work on the foot focuses on the immediate wound area and nail management.

A key step is the gentle debridement of hyperkeratoses (calluses) at the wound edges. Excessive callus formation at the margin of an ulcer acts like a foreign body, exerting continuous pressure on the newly forming epithelial tissue and preventing the migration of young skin cells. Using rotating diamond burrs and precise scalpel technique, this tissue is removed without damaging intact skin.

Professional shortening of the toenails is equally important. Ingrown or thickened nails carry an enormous risk of infection. Using specialised nail nippers and burrs, nails are physiologically shaped and smoothed. Should a nail become ingrown, a nail brace technique (Nagelspange) can be applied to relieve pressure from the nail sulcus.

For pressure relief on vulnerable areas, custom-made silicone orthoses or felt padding are used. They redistribute weight during walking and protect sensitive areas from shear forces. A treatment session generally lasts between 30 and 45 minutes. Depending on findings and wound stage, intervals of two to four weeks are agreed upon. Detailed descriptions of the entire range of services are available at /en/services.

What you can do yourself

Patients can actively support the healing process through consistent measures in daily life. The most important therapeutic measure for a venous leg ulcer is compression therapy. It reduces venous diameter, functionally closes incompetent venous valves, and accelerates blood return to the heart.

Putting on prescribed compression stockings or ulcer stocking systems daily requires patience. They should be applied immediately after rising, before fluid can pool in the legs. Use specialised donning aids to avoid damaging fragile skin through shear forces. If there is any uncertainty regarding fit, consultation with the practice or the medical supply store is recommended.

Skin care around the affected area must be carried out with the utmost care. The skin on the lower leg is extremely dry and prone to cracking. Use water-in-oil skincare products containing lipids and urea in a low concentration of three to five percent. Never apply these ointments directly into the wound, but exclusively on intact surrounding skin. Avoid fragranced lotions, soaps, or aggressive bath additives completely.

Activate your muscle-joint pump through targeted exercises. Sit on a chair and alternately flex your toes strongly upward and extend them downward. Perform circular movements with the ankle joint. These simple exercises should be repeated several times a day for five minutes each. Elevate your legs during rest periods so that the feet are above heart level.

Common mistakes

Daily clinical practice repeatedly reveals typical behavioural patterns that severely compromise healing success or cause closed wounds to reopen. By far the most common mistake is stopping compression therapy on one's own initiative. As soon as the wound shows initial signs of closing or wearing stockings feels too warm during summer, many patients discontinue therapy. The result is rapid recurrence of oedema and reopening of the wound within a few days.

Another serious error concerns the use of home remedies and inappropriate ointments. Applying milking grease, zinc ointment, wound-healing salves, or herbal extracts such as chamomile and arnica directly to the wound bed frequently leads to contact allergies and tissue necrosis. Chronic wounds require a moist, low-germ environment that is exclusively provided by modern, sterile wound dressings such as hydrocolloids, foams, or alginates.

Furthermore, foot baths that are too hot prove extremely harmful. Prolonged soaking softens the skin surrounding the wound, allowing pathogens to penetrate unhindered into deeper tissue layers. Heat also causes vasodilation, further exacerbating venous stasis and swelling. Instead, cleanse feet with a short, lukewarm shower using clear water and gently pat the skin dry without rubbing.

Finally, the importance of footwear is frequently underestimated. Continuing to wear worn-out slippers without heel support or walking barefoot at home carries significant risk of injury. A minor bump against a table corner is enough to disrupt the fragile skin tissue of atrophie blanche.

Current evidence and medical consensus

Scientific evidence on the treatment of leg ulcers underlines the necessity of structured, interdisciplinary care concepts. The current S3 guideline "Local therapy of non-healing and/or chronic wounds" of the German Society for Wound Healing and Wound Care emphasizes that causal therapy always takes precedence over purely local wound management [1]. For venous ulcers, adequate compression therapy is supported by the highest level of evidence.

Studies show that the healing rate of venous ulcers under consistent compression therapy exceeds 70 percent within three to six months, whereas without compression, the recurrence rate reaches nearly 90 percent [2]. The European Wound Management Association highlighted in its position statements that mechanical pressure offloading of the foot and professional debridement of the wound margin are essential factors for cell proliferation [3].

Regarding supportive podiatric care, clinical studies demonstrate that systematic removal of hyperkeratoses and management of nail alterations can reduce the infection rate in high-risk patients by more than 40 percent [4]. A comparative analysis of treatment duration illustrates that patients integrated into a network of general practitioners, specialists, wound managers, and podiatrists show a significantly shorter disease duration than patients under monodisciplinary care [5].

Treatment in Memmingen

For affected individuals in the Allgäu and Unterallgäu region, the practice FREITAG® Podologie GmbH at Kempterstr. 25 in Memmingen offers a highly qualified center for supportive treatment of leg ulcers. As a sectoral practitioner in podiatry (sektorale Heilpraktikerin für Podologie), owner Helga Maria Freitag possesses the in-depth expertise to safely assess high-risk patients and initiate targeted podiatric measures. Further information on her therapeutic background can be found at /en/about.

The practice works in close collaboration with local general practitioners, phlebologists, and wound centres in Memmingen, Upper Swabia, and the surrounding region. Precise coordination of appointments ensures that podiatric measures are perfectly aligned with dressing changes and medical wound care. Scheduling an appointment early helps prevent secondary damage and sustainably improves quality of life. Direct contact details are available at /en/contact.