Diagnostic Imaging Pathways - Foot Ulcer (Diabetic)

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Population Covered By The Guidance

This pathway provides guidance on the imaging of diabetic patients with diabetic foot ulcers.

Date reviewed: August 2013

Date of next review: 2017/2018

Published: August 2013

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No radiation None 0
Minimal radiation Minimal < 1 millisieverts
Low radiation Low 1-5 mSv
Medium radiation Medium 5-10 mSv
High radiation High >10 mSv


Pathway Diagram


Image Gallery

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1a Click to view full size image

Diabetic Foot Osteomyelitis

Image 1a and 1b (Plain Radiography): DP and lateral views of a foot showing cortical erosion of the 4th metatarsal head in keeping with osteomyelitis (arrow). There is a small gas locule in the soft tissue between the 4th and 5th metatarsal heads which could indicate a gas forming organism causing an abscess (arrowhead).

1b Click to view full size image
2 Click to view full size image

Diabetic Foot Osteomyelitis

Image 2 (Plain Radiography): Extensive destructive changes consistent with a pyogenic infection which involves the IP joint of the great toe, all phalanges of the 2nd toe and 2nd MTP joint, all phalanges of the 3rd toe and 3rd MTP joint, proximal phalanx of the 4th toe and 4th MTP joint.

3 Click to view full size image

Diabetic Foot Osteomyelitis

Image 3 (Radionuclide Scan): Dual bone/white cell study (Tc-99 MBP/In-111 WBC). Delayed bone scan demonstrates intense focal uptake in the medial aspect of the proximal part of the distal phalanx of the right 1st toe. White cell study demonstrates intense focal uptake corresponding to the medial aspect of the proximal part of the distal phalanx of the right 1st toe. This scintigraphic appearance is consistent with osteomyelitis.

There is also focal intense uptake on bone scan in the inferior aspect of the calcaneo-cuboidal junction, which is not demonstrated on white cell study. This may represent neuroarthropathy or tendonitis.

4 Click to view full size image

Diabetic Foot Osteomyelitis

Image 4 (Bone Biopsy): Needle biopsy under fluoroscopic guidance of a bony erosion involving the proximal phalanx of the right great toe. Patient had a preceding dual bone/white cell study which showed a scintigraphic appearance consistent with partially treated osteomyelitis.

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Teaching Points


Diabetic Foot Ulcer

Clinical Findings


Plain Radiography


Magnetic Resonance Imaging (MRI)


Nuclear Medicine Scans


Bone Biopsy



Date of literature search: April 2013

The search methodology is available on request. Email

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

  1. Butalia S, Palda VA, Sargeant RJ, Detsky AS, Mourad O. Does this patient with diabetes have osteomyelitis of the lower extremity? JAMA. 2008;299(7):806-13. (Level II evidence)
  2. Newman LG, Waller J, Palestro CJ, Schwartz M, Klein MJ, Hermann G, et al. Unsuspected osteomyelitis in diabetic foot ulcers. Diagnosis and monitoring by leukocyte scanning with indium in 111 oxyquinoline. JAMA. 1991;266(9):1246-51. (Level II evidence)
  3. Wraight PR, Lawrence SM, Campbell DA, Colman PG. Creation of a multidisciplinary, evidence based, clinical guideline for the assessment, investigation and management of acute diabetes related foot complications. Diabet Med. 2005;22(2):127-36. (Evidence based guideline)
  4. Ertugrul MB, Baktiroglu S, Salman S, Unal S, Aksoy M, Berberoglu K, et al. The diagnosis of osteomyelitis of the foot in diabetes: microbiological examination vs. magnetic resonance imaging and labelled leucocyte scanning. Diabet Med. 2006;23(6):649-53. (Level II evidence)
  5. Margolis D, Allen Taylor L, Hoffstad O, Berlin J. Diabetic neuropathic foot ulcers and amputation. Wound Repair Regen. 2005;13(3):230-6. (Level II evidence)
  6. Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR, et al. Diabetic foot disorders: a clinical practice guideline (2006 revision). J Foot Ankle Surg. 2006;45(5,Supplement):S1-66. (Review article)
  7. Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2004;39(7):885-910. (Review article)
  8. Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW. Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients. JAMA. 1995;273(9):721-3. (Level III evidence)
  9. Lavery L, Armstrong D, Peters EJG, Lipsky B. Probe-to-bone test for diagnosing diabetic foot osteomyelitis: reliable or relic? Diabetes Care. 2007;30(2):270-4. (Level IV evidence)
  10. Shone A, Burnside J, Chipchase S, Game F, Jeffcoate W. Probing the validity of the probe-to-bone test in the diagnosis of osteomyelitis of the foot in diabetes. Diabetes Care. 2006;29(4):945. (Level III evidence)
  11. Kaleta JL, Fleischli JW, Reilly CH. The diagnosis of osteomyelitis in diabetes using erythrocyte sedimentation rate: a pilot study. J Am Podiatr Med Assoc. 2001;91(9):445-50. (Level IV evidence)
  12. Rajbhandari SM, Sutton M, Davies C, Tesfaye S, Ward JD. 'Sausage toe': a reliable sign of underlying osteomyelitis. Diabet Med. 2000;17(1):74-7. (Level III evidence)
  13. Armstrong DG, Lavery LA, Sariaya M, Ashry H. Leukocytosis is a poor indicator of acute osteomyelitis of the foot in diabetes mellitus. J Foot Ankle Surg. 1996;35(4):280-3. (Level IV evidence)
  14. Oyen WJ, Netten PM, Lemmens JA, Claessens RA, Lutterman JA, van der Vliet JA, et al. Evaluation of infectious diabetic foot complications with indium-111-labeled human nonspecific immunoglobulin G. J Nucl Med. 1992;33(7):1330-6. (Level IV evidence)
  15. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):e132-73. (Evidence based guideline)
  16. Dinh MT, Abad CL, Safdar N. Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic foot ulcers: meta-analysis. Clin Infect Dis. 2008;47(4):519-27. (Level I evidence)
  17. Pineda C, Espinosa R, Pena A. Radiographic imaging in osteomyelitis: the role of plain radiography, computed tomography, ultrasonography, magnetic resonance imaging, and scintigraphy. Semin Plastic Surg. 2009;23(2):80-9. (Review article)
  18. Kapoor A, Page S, LaValley M, Gale D. R, Felson D. T. Magnetic resonance imaging for diagnosing foot osteomyelitis: A meta-analysis. Arch Intern Med. 2007;167(2):125-32. (Level II evidence)
  19. Capriotti G, Chianelli M, Signore A. Nuclear medicine imaging of diabetic foot infection: results of meta-analysis. Nucl Med Commun. 2006;27(10):757-64. (Level II evidence)
  20. Termaat MF, Raijmakers PGHM, Scholten HJ, Bakker FC, Patka P, Haarman HJTM. The accuracy of diagnostic imaging for the assessment of chronic osteomyelitis: a systematic review and meta-analysis. J Bone Joint Surg Am. 2005;87(11):2464-71. (Level I/II evidence)
  21. Nawaz A, Torigian DA, Siegelman ES, Basu S, Chryssikos T, Alavi A. Diagnostic performance of FDG-PET, MRI, and plain film radiography (PFR) for the diagnosis of osteomyelitis in the diabetic foot. Molecular Imaging and Biology : MIB. 2010;12(3):335-42. Available from: ProQuest Central; ProQuest Health & Medical Complete; ProQuest Nursing & Allied Health Source. (Level II evidence)
  22. White LM, Schweitzer ME, Deely DM, Gannon F. Study of osteomyelitis: utility of combined histologic and microbiologic evaluation of percutaneous biopsy samples. Radiology. 1995;197(3):840-2. (Level III evidence)
  23. Senneville E, Melliez H, Beltrand E, Legout L, Valette M, Cazaubie M, et al. Culture of percutaneous bone biopsy specimens for diagnosis of diabetic foot osteomyelitis: concordance with ulcer swab cultures. Clin Infect Dis. 2006;42(1):57-62. (Level II evidence)

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Information for Consumers

Information from this website

Information from the Royal Australian and New Zealand College of Radiologists’ website

Consent to Procedure or Treatment

Radiation Risks of X-rays and Scans

Bone Scan

Magnetic Resonance Imaging (MRI)

Positron Emission Tomography (PET)

Plain Radiography (X-ray)

Gadolinium Contrast Medium

Iodine-Containing Contrast Medium

Magnetic Resonance Imaging (MRI)

Plain Radiography/X-rays

Radiation Risk of Medical Imaging During Pregnancy

Radiation Risk of Medical Imaging for Adults and Children

Nuclear Medicine

Nuclear Medicine Bone Scan



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