Diabetic foot ulcers are usually described in terms of wound size, infection, and amputation risk. Yet for the person living with an ulcer, the day-to-day experience—pain, restricted walking, disrupted work and social life—is often what matters most. Health-related quality of life (HRQoL) is the standardized way researchers capture that experience, and a growing body of research shows that it is substantially reduced in people with diabetic foot ulcers.
How Much Is Quality of Life Reduced?
A 2019 meta-analysis by Khunkaew, Fernandez, and Sim in Quality of Life Research pooled 12 studies of adults with diabetic foot ulcers. Using the Short Form-36 (SF-36), the authors found poor HRQoL on four of the eight subscales. Pooled mean scores (on a 0–100 scale, where higher is better) were roughly 43 for physical functioning, 21 for role limitations due to physical health, 40 for general health, and 46 for vitality. The role-physical result is especially notable: it indicates that physical health problems substantially interfere with work and usual daily activities.
The same review identified factors associated with worse HRQoL, including pain, higher C-reactive protein, larger ulcer size, a lower ankle-brachial index, higher glycated hemoglobin, and higher body mass index. Many of these are the same clinical markers that predict poor wound outcomes, which suggests that quality of life and physical disease severity are closely linked.
Does Healing Restore Quality of Life?
It might be assumed that quality of life improves only when an ulcer closes. The evidence is more nuanced. In a prospective cohort study published in Angiology in 2017, Spanos and colleagues followed 103 consecutive patients with diabetic foot ulcers for 12 months. During follow-up, 41% of ulcers healed, 41% of patients underwent a minor amputation, 18% underwent a major amputation, and 18% died. Scores on the Diabetic Foot Ulcer Scale-Short Form improved across all domains (P < .0001) regardless of outcome, and no single outcome—healing or amputation—was clearly superior for quality of life.
These findings should be interpreted cautiously. The study was small and non-randomized, and patients who die or are lost to follow-up cannot report their quality of life. Still, the results suggest that engagement with structured care, which also improved hygiene and self-management in this cohort, may itself contribute to patients’ sense of well-being.
Minor Amputation and Quality of Life
Because amputation is widely feared, a common concern is that any amputation will markedly worsen quality of life. Pickwell and colleagues addressed this in an observational study from the Eurodiale consortium, published in Diabetes/Metabolism Research and Reviews in 2017. They compared patients who underwent minor amputation with those treated conservatively and concluded that minor amputation did not negatively affect HRQoL relative to conservative treatment. This is consistent with the idea that removing infected or non-viable tissue and achieving a stable, functional foot can be preferable to prolonged non-healing. As an observational comparison, it cannot fully eliminate differences in baseline severity between groups, and it applies to minor, not major, amputation.
Why Measuring Quality of Life Matters
Pain deserves particular attention. The 2019 meta-analysis flagged pain as a correlate of poorer HRQoL scores. Because pain is modifiable, assessing it routinely is one practical way to address quality of life directly rather than treating it only as a by-product of wound healing.
The meta-analysis authors also called for evidence-based interventions designed specifically to improve HRQoL, noting that most existing studies describe the problem rather than test solutions. Patient-reported outcome measures such as the SF-36, the EQ-5D, and the Diabetic Foot Ulcer Scale allow clinicians and researchers to track whether treatments improve how patients function and feel, not only how their wounds look.
Key Takeaways
Diabetic foot ulcers are associated with clearly impaired physical functioning, general health, vitality, and ability to perform usual roles. Pain, larger wounds, reduced arterial perfusion, and poorer metabolic control track with worse scores. Quality of life can improve over a year of structured care even when the ulcer does not heal, and minor amputation has not been shown to worsen HRQoL compared with conservative treatment. Routine measurement of patient-reported outcomes, with particular attention to pain, offers a more complete picture of treatment success than wound closure alone.
References
- Khunkaew S, Fernandez R, Sim J. Health-related quality of life among adults living with diabetic foot ulcers: a meta-analysis. Quality of Life Research. 2019;28(6):1413–1427.
- Spanos K, Saleptsis V, Athanasoulas A, Karathanos C, Bargiota A, Chan P, Giannoukas AD. Factors associated with ulcer healing and quality of life in patients with diabetic foot ulcer. Angiology. 2017;68(3):242–250.
- Pickwell K, Siersma V, Kars M, Apelqvist J, Bakker K, Edmonds M, et al. Minor amputation does not negatively affect health-related quality of life as compared with conservative treatment in patients with a diabetic foot ulcer: an observational study. Diabetes/Metabolism Research and Reviews. 2017;33(3):e2867.
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