Clinical Care
Why lower-limb health belongs in every chronic disease conversation
Chronic lower-limb wounds create a growing clinical and health-system burden. Prevention and early identification must be embedded in chronic disease strategy. By Mariam Botros, Janet L. Kuhnke, and Tobi Mark
The prevention and management of skin breakdown in lower limb lymphedema presents significant challenges. Internal prevalence studies have shown that over 40% of patients experience active leg ulcers. For many years, the role of the lymphatics has been known to be involved in tissue fluid transport and immune function. New research also reveals their vital role in the function of organs like the brain, lungs, and kidneys. In lower limbs, the lymphatic, vascular, and extracellular systems work together to transport fluids, solutes, and macromolecules. Chronic conditions like diabetes and heart disease heavily impact our legs and feet daily, yet these areas are frequently overlooked. This article highlights a key point that we must top treating leg issues in isolation and references Wounds Canada’s best practice recommendations and resources for effective lower-limb wound prevention and management. – Dr. David Keast
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he foot and leg are often where chronic illness becomes visible, disabling, and costly. A lower-limb wound signals more than tissue damage: it can expose advancing systemic disease, require prolonged care, and threaten mobility, independence, and quality of life. Hard-to-heal lower-limb wounds rarely have a single cause. Metabolic, vascular, neurologic, inflammatory, functional, and social factors often intersect. Diabetes, chronic venous disease, peripheral arterial disease, chronic kidney disease, chronic edema or lymphedema, immobility, frailty, smoking, and delayed access to care may all contribute.1,2 The wound is visible, but its causes and consequences extend across the chronic disease system. For people living with lower-limb lymphedema or chronic edema, these risks are especially important because swelling, skin changes, reduced mobility, infection risk and wounds can
reinforce one another over time. The Centers for Disease Control and Prevention defines chronic diseases as conditions lasting one year or more that require ongoing medical attention, limit activities of daily living, or both.3 The World Health Organization similarly describes noncommunicable diseases as long-duration conditions shaped by genetic, physiological, environmental, and behavioural factors.4 Lower-limb complications reflect these definitions through both their underlying disease processes and their effects on healing, mobility, quality of life, hospitalization, amputation, and mortality. Preventing first and recurrent wounds, identifying risk early, and escalating care before tissue loss occurs are therefore essential components of chronic disease prevention. The potential system impact is substantial: wound care in Canada was estimated to cost more than $13 billion in 20245,
while hospital stays involving lower-limb complications of diabetes cost approximately $750 million annually.6 Earlier intervention can reduce avoidable suffering, hospitalization, and cost. Lower-limb health also connects disease control with the outcomes that matter most to people. Laboratory values do not reveal whether someone can walk safely, wear appropriate footwear, manage compression, attend appointments, continue working, or participate in family life. A plan may appear clinically complete while a preventable wound develops. Including the legs and feet in routine chronic disease care makes function, independence, and quality of life visible. How chronic disease becomes a lower-limb wound
Several chronic disease pathways converge in the lower limb. In diabetes, neuropathy can allow repetitive trauma, footwear injury,
Mariam Botros, CEO of Wounds Canada; Janet L. Kuhnke, Associate Professor at Cape Breton University; and Tobi Mark, Professor at the Michener Institute, are collaborative leaders advancing skin health, wound care, diabetes-related foot care, and lower-limb health. Through education, advocacy, research, and partnerships, they promote prevention, timely referral, equitable access, and person-centred care for Canadians.
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or skin breakdown to go unnoticed, while hyperglycemia can impair immune response and tissue repair.7,8 Peripheral arterial disease and smoking reduce perfusion and tissue oxygenation, limiting healing and increasing the risk of infection, gangrene, and amputation.9 Chronic venous disease causes venous hypertension, inflammation, edema, skin changes, and recurrent ulceration. It should be recognized as a major chronic disease issue, not a problem confined to wound clinics.10 When arterial perfusion is adequate or appropriately assessed, compression is central to treatment. Activity, calf-musclepump function, skin care, edema control, and recurrence prevention are equally important. Chronic edema also demands attention. Edema that persists for more than three months and responds minimally to elevation or diuretics is considered lymphedema. It may go unrecognized until tissue changes, leakage, infection, or wounds develop. Wounds Canada’s recommendations emphasize early assessment, integrated treatment, and lifelong self-management,
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linking chronic disease care with mobility, skin health, and wound prevention.11 Although these mechanisms differ, the trajectory is similar: systemic risk culminates in local tissue failure and functional loss. A hard-to-heal wound should therefore be treated as a sentinel chronic disease event, one that triggers investigation of the underlying causes and barriers to healing, not simply a change in dressing. Clinical distinctions remain essential. A diabetes-related foot ulcer requires assessment of neuropathy, pressure, infection, perfusion, glycemic control, footwear, offloading, and recurrence risk. A venous leg ulcer requires venous and edema assessment, compression when safe, mobility support, and prevention planning. An arterial ulcer requires objective vascular assessment, cardiovascular risk reduction, smokingcessation support, and timely referral. Mixedetiology wounds demand careful decisions about compression, offloading, debridement, and referral. Treatment must be specific, but the strategy must be integrated because many people live with multiple chronic conditions.
Edema that persists for more than three months and responds minimally to elevation or diuretics is considered lymphedema.
From fragmented care to an integrated strategy
Integration does not mean every clinician provides every service. It means every point of care can recognize risk, begin an appropriate assessment, and connect the person with the right expertise. Primary care can incorporate routine lower-limb screening; community and home-care teams can identify changes between visits; foot and wound-care clinicians can recognize the need for vascular, venous, or systemic assessment; and specialists can support rapid escalation. Throughout, the person and their care partners must remain central to a clear, coordinated, long-term plan.
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Embedding lower-limb health in chronic disease strategy protects not only limbs but also mobility, independence, dignity, and quality of life.
Embedding lower-limb health in chronic disease strategy requires six linked actions.
edema is present, assessment should establish whether compression is safe and identify a sustainable plan for compression, mobility, and edema management. This is especially important in mixed disease. Missing ischemia may lead to unsafe treatment or irreversible tissue loss; missing venous hypertension or lymphedema may result in persistent swelling, recurrent wounds, and infection. Integrated pathways help clinicians address all contributing causes. 4 Make self-management possible
1 Include lower-limb screening in routine care
Foot and leg assessment should begin before a wound develops and be repeated as risk changes—particularly for people living with diabetes, venous or arterial disease, kidney disease, chronic edema, lymphedema, frailty, reduced mobility, or previous ulceration. A focused assessment includes skin integrity, footwear, deformity, protective sensation, pulses, edema, pain, gait, mobility, wound and amputation history, smoking, and the person’s ability to inspect and care for their lower limbs.8,12 2 Use risk stratification to guide care
Risk stratification moves the system from crisis response to planned prevention. People at lower risk may need periodic screening and education; those with neuropathy, vascular disease, deformity, edema, lymphedema, or previous ulceration need closer monitoring and protective intervention. A new wound, infection, suspected ischemia, gangrene, acute swelling, or delayed healing requires prompt escalation. 3 Assess vascular and venous contributors early
A non-healing wound should never be treated as a dressing problem alone. Assessment must consider perfusion, venous function, edema, pressure, infection, and systemic disease. Suspected arterial disease requires objective testing and timely vascular referral because pulse palpation alone may be insufficient. When venous disease or chronic
People and care partners need practical, culturally safe information tailored to health literacy, dexterity, vision, cognition, and living circumstances. This includes daily skin and limb inspection, skin protection, appropriate footwear, compression or offloading, activity, warning signs, and recurrence prevention. Education alone is not enough. Selfmanagement also depends on access to primary, foot, wound, and home care; vascular testing; compression; offloading devices; therapeutic footwear; transportation; and affordable supplies. A person cannot follow a plan that is unavailable or unaffordable. Chronic disease strategy must address individual capability and system barriers. 5 Coordinate interprofessional care
Lower-limb care may involve primary care, nursing, chiropody or podiatry. Care may include wound specialists, vascular services, endocrinology, infectious diseases and rehabilitation. Orthotics and pharmaceutical care may be required. Attention must be paid to mental health, plus patient and care-partner leadership. Shared pathways create common expectations for prevention, monitoring, referral, urgent escalation, and recurrence prevention while clarifying responsibility. Coordination must continue after wound closure because the underlying chronic disease remains. Ongoing compression, protective footwear, activity, skin care, risk-factor management, and surveillance may be needed to preserve mobility and prevent recurrence.
Transitions between settings require particular attention. Information about wound cause, vascular status, compression or offloading, medications, warning signs, and follow-up responsibility must travel with the person. Without a shared plan, discharge or transfer can interrupt effective therapy and place a recently healed or high-risk limb in danger. 6 Measure outcomes that matter
Lower-limb health should appear in chronic disease dashboards and quality-improvement plans. Measures should include screening and risk-stratification rates as well as referral times and access to vascular or venous assessment. Other considerations include the use of indicated compression or offloading, healing time, and recurrence. Additional factors that may impact outcomes are infection, emergency visits, hospitalization, amputation, mobility, quality of life, and ability to self-manage. Results must also be examined through an equity lens. Geography, income, housing, access to primary care, and other structural factors influence whether people receive timely assessment and treatment. Equity-sensitive measurement can reveal where systems are failing people who face the greatest barriers. Why lower-limb health must be part of the conversation
Lower-limb wounds are visible warning signs of chronic disease progression and indicators of health equity and system performance. Evidence-based pathways, including Wounds Canada’s Best Practice Recommendations for Skin Health and Wound Management 2025 and Care at Home resources and training programs can help move care from reacting to tissue loss to identifying risk early, coordinating timely intervention, preserving function, and preventing recurrence.1 Embedding lower-limb health in chronic disease strategy protects not only limbs but also mobility, independence, dignity, and quality of life. LP References can be found at https:// ww.canadalymph.ca/pathways/all-issues
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