Diabetic foot ulcers (DFUs) are usually discussed in terms of the wound, the nerves and the blood supply. Increasingly, researchers are also looking at the person carrying the wound. Frailty, a state of reduced physiological reserve, and sarcopenia, the loss of skeletal muscle mass and strength, are common in older adults with diabetes. Recent studies suggest both may influence whether an ulcer heals, whether a patient returns to hospital, and how long they survive.
Frailty and Sarcopenia: Two Related but Distinct Concepts
Frailty describes a vulnerability to stressors that arises from the accumulated decline of multiple body systems. It is measured with tools such as the FRAIL scale or a deficit-accumulation Frailty Index. Sarcopenia is narrower: it refers specifically to low muscle mass and, in many definitions, low muscle strength, often assessed by dual-energy X-ray absorptiometry, CT-measured psoas muscle area, or handgrip dynamometry. The two overlap, but a person can have one without the other, which is why studies of foot disease often examine them side by side.
How Common Is Frailty in Diabetic Foot Disease?
A 2023 systematic review by Fernando and colleagues in the Annals of Vascular Surgery pooled 10 cohort studies of people with chronic limb-threatening ischemia and diabetes-related foot ulcers. Frailty was identified in 27% to 88% of people with chronic limb-threatening ischemia and in 71% of people with diabetes-related foot ulcers. Frailty was associated with more severe ischemia and tissue loss at presentation, and with higher risks of readmission, limb amputation and all-cause mortality. The authors cautioned that the screening tools varied widely and that frailty was often poorly defined, so the pooled picture should be read with care.
Frailty and Ulcer Healing
Maltese and colleagues, writing in the Journal of Nutrition, Health & Aging in 2022, followed 76 consecutive hospitalized patients with DFUs. Using a Frailty Index above 0.25 as the threshold, 74% were frail. At six months, 81.5% of frail patients had a non-healed ulcer compared with 55% of non-frail patients, and 90.3% of frail patients had been re-hospitalized for any cause compared with 54% of non-frail patients. In multivariable analysis, frailty was independently associated with non-healing (odds ratio 5.54; 95% CI 1.28–23.91). The cohort was small and from a single setting, so the wide confidence interval is a reminder that the size of the effect is uncertain even though the direction is consistent with other work.
Sarcopenia, Muscle Strength and Survival
Sarcopenia appears to be linked to foot disease before an ulcer is even established. In a cross-sectional study of 1,105 people with type 2 diabetes, Cheng and colleagues (Scientific Reports, 2017) found sarcopenia, defined by a low DXA-derived skeletal muscle index, in 35.3% of those with newly diagnosed diabetic foot disease versus 16.4% of those without. After adjustment for age, diabetes duration, complications and medications, the odds ratio was 2.06 (95% CI 1.08–3.95). Because the design was cross-sectional, the authors could not say whether sarcopenia contributes to foot disease or results from it.
A more recent prospective study by Hon and colleagues in the Journal of Foot and Ankle Research (2025) followed 100 people with active diabetes-related foot ulceration for up to 36 months. Frailty (FRAIL scale) was present in 47% and sarcopenia in 16%. Stronger handgrip was associated with ulcer healing (odds ratio 3.83 for high versus low grip strength; 95% CI 1.35–10.92), and higher grip strength was associated with lower mortality after adjustment (hazard ratio 0.46; 95% CI 0.22–0.997). Frailty itself was not significantly associated with healing in that cohort, and no measure predicted amputation-free survival. Overall survival at three years was roughly 55%. The authors noted the small sample, the predominance of men, and the sparse data available for adjusted models.
Interpreting the Evidence
These studies are observational, mostly small, and use different definitions of frailty and sarcopenia, so they cannot show that frailty causes poor outcomes or that treating it would change them. Frail patients also tend to have more kidney disease, vascular disease and other comorbidities that independently worsen healing. Findings are not fully consistent either: frailty predicted non-healing in one cohort but not in another, while handgrip strength, a simple and inexpensive measure, was informative in the latter. What the literature does support is that frailty and low muscle function are frequent in people with DFUs and mark a group at higher risk of poor outcomes.
Key Takeaways
Frailty is highly prevalent among people with diabetic foot ulcers, with estimates around 70% in pooled and hospital-based cohorts. It is associated with more advanced disease at presentation, slower or absent healing, readmission and mortality. Sarcopenia is more common in people with diabetic foot disease, and lower handgrip strength has been associated with poorer healing and survival. Heterogeneous definitions, small samples and the observational nature of the data limit certainty, and whether interventions such as nutrition support or resistance exercise improve foot outcomes remains to be tested in dedicated trials.
References
- Fernando ME, Blanchette V, Mishra R, Zulbaran-Rojas A, Rowe V, Mills JL, Armstrong DG, Najafi B. Frailty in people with chronic limb threatening ischemia and diabetes-related foot ulcers: a systematic review. Annals of Vascular Surgery. 2023;89:322–337.
- Maltese G, Basile G, Meehan H, Fuller M, Cesari M, Fountoulakis N, Karalliedde J. Frailty is associated with impaired diabetic foot ulcer healing and all-cause re-hospitalization. Journal of Nutrition, Health & Aging. 2022;26(2):169–173.
- Cheng Q, Hu J, Yang P, et al. Sarcopenia is independently associated with diabetic foot disease. Scientific Reports. 2017.
- Hon KY, Bain M, Edwards S, Pena G, McMillan N, Fitridge R. The association of sarcopenia and frailty in diabetes-related foot disease: a 3-year prospective evaluation. Journal of Foot and Ankle Research. 2025;18(1):e70038.
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