, Volume 31, Issue 9, pp 652–656 | Cite as

Direct measurement of capillary blood flow in the diabetic neuropathic foot

  • M. D. Flynn
  • M. E. Edmonds
  • J. E. Tooke
  • P. J. Watkins


The two major components of the microcirculation in the diabetic neuropathic foot have been examined in detail. Nutritive capillary blood flow was measured directly using the non-invasive technique of television microscopy, applied to the toe nailfold. Arteriovenous shunt flow was assessed using the technique of laser Doppler flowmetry, applied to the toe pulp. Fourteen diabetic patients with peripheral and autonomic neuropathy, 11 with no clinical evidence of neuropathy and 14 normal subjects were studied. Laser Doppler flowmetry (predominantly arteriovenous shunt flow) was increased more than three-fold (p<0.01) in the diabetic patients with neuropathy compared to control subjects, (median 3.57, interquartile range 2.00–5.32 volts vs median 0.93, interquartile range 0.47–2.36 volts respectively). There was no evidence of skin capillary closure. The calculated capillary blood flow (erythrocyte flux) was significantly increased in the diabetic neuropathic patients compared to control subjects (median 76.4, interquartile range 34.4–109.8 picolitres/s vs median 23.2, range 8.0–44.8 picolitres/s, p<0.01). This study demonstrates that foot skin capillary blood flow is increased in diabetic patients with neuropathy. There is, therefore, no evidence to support the supposition that capillary ischaemia, either secondary to a “capillary steal phenomenon” or “advanced microangiopathy”, is a feature of diabetic neuropathy under resting conditions.

Key words

Blood flow capillaries diabetic neuropathy foot television microscopy 


  1. 1.
    Pryce TD (1893) On diabetic neuritis with a clinical and pathological description of three cases of diabetic pseudo-tabes. Brain 16: 416–424Google Scholar
  2. 2.
    Scarpello JHB, Martin TRP, Ward JD (1980) Ultrasound measurements of pulse wave velocity in the peripheral arteries of diabetic subjects. Clin Sci 58: 53–57Google Scholar
  3. 3.
    Edmonds ME, Roberts VC, Watkins PJ (1982) Blood flow in the diabetic neuropathic foot. Diabetologia 22: 9–15Google Scholar
  4. 4.
    Archer AG, Roberts VC, Watkins PJ (1984) Blood flow patterns in painful diabetic neuropathy. Diabetologia 27: 563–567Google Scholar
  5. 5.
    Rayman G, Hassan A, Tooke JE (1986) Blood flow in the skin of the foot related to posture in diabetes mellitus. Br Med J 292: 87–90Google Scholar
  6. 6.
    Cronenwett JL, Lindenaur SM (1977) Direct measurement of arteriovenous anastomatic blood flow after lumbar sympathetectomy. Surgery 82: 82–89Google Scholar
  7. 7.
    Partsch H (1977) Neuropathies of the ulcero-mutilating types. Clinical aspects, classification, circulation measurements. Vasa [Suppl] 6: 1–48Google Scholar
  8. 8.
    Boulton AJM, Scarpello JHB, Ward JD (1981) Venous oxygenation in the diabetic neuropathic foot: evidence of arteriovenous shunting. Diabetologia 22: 6–8Google Scholar
  9. 9.
    Watkins PJ, Edmonds ME (1983) Sympathetic nerve failure in diabetes. Diabetologia 25: 73–77Google Scholar
  10. 10.
    Pickering GW, Hess W (1933) Vasodilatation in the hands and feet in response to wanning the body. Clin Sci 1: 213–223Google Scholar
  11. 11.
    Coffman JD (1972) Total and nutritional blood flow in the finger. Clin Sci 42: 243–250Google Scholar
  12. 12.
    Borkowski M (1973) An experimental study on the role of arterio-venous anastomosis in the pathogenesis of trophic ulcer. Arch Immunol Ther Exp (Warsz) 21: 363–375Google Scholar
  13. 13.
    Deanfield JE, Daggett PR, Harrison MJG (1980) The role of autonomic neuropathy in diabetic foot ulceration. J Neurol Sci 47: 203–210Google Scholar
  14. 14.
    Edmonds ME, Nicoliades KH, Watkins PJ (1986) Autonomiceuropathy and diabetic neuropathic foot ulceration. Diabetic Medicine 3: 56–59Google Scholar
  15. 15.
    Ward JD (1982) The diabetic leg. Diabetologia 22: 141–147Google Scholar
  16. 16.
    Ditzel J (1968) Functional microangiopathy in diabetes mellitus. Diabetes 17: 388–397Google Scholar
  17. 17.
    Ward JD, Boulton AJM, Simms JM, Sandler DA, Knight G (1983) Venous distension in the diabetic neuropathic foot (physical sign of arteriovenous shunting). J R Soc Med 76: 1011–1014Google Scholar
  18. 18.
    Yao ST, Hobbs JT, Irvine WT (1969) Ankle systolic pressure measurement in arterial disease affecting the lower extremity. Br J Surg 56: 676–679Google Scholar
  19. 19.
    Ewing DJ, Clarke BF (1982) Diagnosis and management of diabetic autonomic neuropathy. Br Med J 285: 916–918Google Scholar
  20. 20.
    Ewing DJ, Clarke BF (1986) Autonomic neuropathy: it's diagnosis and prognosis. In: Watkins PJ (ed) Clinics in endocrinology and metabolism, Vol 15, No 4. Saunders, London Philadelphia Toronto, pp 855–888Google Scholar
  21. 21.
    Guy RJC, Clark CA, Malcolm PN, Watkins PJ (1985) Evaluation of thermal and vibration sensation in diabetic neuropathy. Diabetologia 28: 131–137Google Scholar
  22. 22.
    Bollinger A, Butti P, Barras J-P, Trachsler H, Siegenthaler W (1974) Red blood cell velocity in nailfold capillaries of man measured by a television microscope technique. Microvasc Res 7: 61–72Google Scholar
  23. 23.
    Nilsson GE, Tenland T, Oberg PA (1980) Evaluation of a laser Doppler flow meter for measurement of tissue blood flow. IEEE Trans Biomed Eng 27: 597–604Google Scholar
  24. 24.
    Grant RT, Bland EF (1931) Observations on arteriovenous anastomoses in human skin and in the birds foot with special reference to the reaction to cold. Heart 15: 385–411Google Scholar
  25. 25.
    Mescon H, Hurley HJ, Moretti G (1956) The anatomy and histochemistry of the arteriovenous anastomoses in human digital skin. J Invest Dermatol 27: 133–144Google Scholar
  26. 26.
    Tooke JE, Ostergren J, Fagrell B (1983) Synchronous assessment of human skin microcirculation by laser Doppler flowmetry and dynamic capillaroscopy. Int J Microcirc Clin Exp 2: 277–284Google Scholar
  27. 27.
    Low PA, Neumann C, Dyck PJ, Fealey RD, Tuck RR (1983) Evaluation of skin vasomotor reflexes by using laser Doppler velocimetry. Mayo Clin Proc 58: 583–592Google Scholar
  28. 28.
    Fagius J (1982) Microneurographic findings on diabetic polyneuropathy with special reference to sympathetic nerve activity. Diabetologia 23: 415–420Google Scholar
  29. 29.
    Delius W, Hagbarth KE, Hongell A, Wallin BC (1972) Manoeuvres affecting sympathetic outflow in human skin nerves. Acta Physiol Scand 84: 177–186Google Scholar
  30. 30.
    Nelms JD (1963) Functional anatomy of skin related to temperature regulation. Fed Proc 22: 933–936Google Scholar
  31. 31.
    Corcoran CA, Yudkin JS (1987) Loss of spontaneous variability of finger tip blood flow in diabetic autonomic neuropathy. Clin Sci 72: 557–562Google Scholar

Copyright information

© Springer-Verlag 1988

Authors and Affiliations

  • M. D. Flynn
    • 1
    • 3
  • M. E. Edmonds
    • 1
  • J. E. Tooke
    • 2
  • P. J. Watkins
    • 1
  1. 1.Diabetic DepartmentKing's College HospitalDenmark Hill
  2. 2.Department of PhysiologyCharing Cross and Westminster Medical SchoolLondonUK
  3. 3.Medical Unit Torridge Ward Level 8Royal Devon and Exeter HospitalExeterUK

Personalised recommendations