Peripheral artery disease (PAD) affects approximately seven percent of adults in the United States (U.S.), about 8.5 million people [1]. Many of these patients may be asymptomatic, with typical intermittent claudication (IC) occurring in only 10% to 30% of patients [2]. However, patients with PAD, regardless of leg symptoms, have a poorer overall prognosis as well as decreased limb function compared to those without PAD [1]. Hospitalization costs for people with PAD per year in the U.S. have been reported as six billion dollars [3].

Diabetes mellitus (DM) can occur with or without PAD. An estimated 38.1 million U.S. adults have DM and almost 98 million have prediabetes (A1C between 5.7% and 6.4% and/or fasting plasma glucose 100–125 mg/dL or 110–125 mg/dL) [4]. Diabetic foot ulceration (DFU) develops in as many as 34% of those with DM [5]. After wounds close, wounds recur at high rates (ie, approximately 40% and 65% recur within the first and fifth years, respectively) [6]. The cost of diabetic foot disease, including DFU, in the U.S. is also high with reported costs being approximately a third of total DM direct costs (eg, U.S. direct cost of DM in 2017 was $237 billion) [7]. Moreover, life costs (ie, 5-year mortality rates) for people with DFU (30.5%), minor amputation (46.2%), and major amputation (56.6%) exceed that of combined cancer which has a 5-year mortality rate of 31.0% [7].

The true prevalence of concomitant PAD and DM is difficult to determine as the severity and symptomatology of PAD can vary widely. This results in many patients with preclinical disease going undetected for a period of time due to lack of symptoms. Using the best available estimates, DM is associated with a two- to four-fold increase in the prevalence of PAD [8]. The presence of DM increases both the incidence and disease severity of PAD. In particular, patients with DM and PAD have more frequent infrapopliteal or tibial artery disease and vessel calcification than patients without DM [8]. Clinically, patients with these disease processes and complications present with skin breakdown, challenges with mobility, difficulty meeting exercise guidelines for health, and an elevated risk for wound recurrence once ulcers have closed.

An independent economic analysis conducted by the American Physical Therapy Association investigated the cost-effectiveness of physical therapist services combined with optimal monitored medical care vs monitored medical care alone in managing IC due to PAD. They found that the addition of physical therapist services resulted in an average net benefit of $24,125 including all hidden costs (eg, patient's time, pain, missed life events) and the dollars paid for the services [9].

The involvement of physical therapists as a part of the multidisciplinary team that manages patients with PAD and DM, alone or in combination, can make a significant impact on skin health, mobility, quality-of-life, and surgical outcomes in these patients. Physical therapists, as part of the multidisciplinary team, are well-positioned to address return to function, mobility, and the public health problem of DFU recurrence. The physical therapist practice pattern is such that patients are seen across multiple visits and for extended periods of time. Physical therapist education is broad, including what is generally understood as part of its curriculum (eg, anatomy; physiology; pathophysiology; exercise science; musculoskeletal science; neuroscience; intervention practice for the musculoskeletal, neurological, cardiovascular pulmonary, and integumentary systems across the lifespan). Beyond these topics, health promotion and wound management are also core parts of the Doctor of Physical Therapy curriculum [10].

In particular, a 2020 study by Moore et al [11] found that of the surveyed Doctor of Physical Therapy programs, 42% spent between 10 and 29 contact hours, 36% spent 30 to 35 contact hours, and 14% spent more than 50 contact hours on wound management. Medical school programs provide approximately 9 hours of wound care education [11]. Postgraduation wound management residencies (minimum of 12 months) are available for physical therapists who wish to focus more on this particular practice area [12]. National board certification for physical therapists specializing in wound management is available as a discipline-specific credential through the American Board of Physical Therapy Specialties [13] or as a multidisciplinary credential through the American Board of Wound Management [14]. The purpose of this review is to highlight the role of physical therapists as team members in caring for patients with vascular compromise and/or DM.