Sole Ulcers

Sole ulcers, also known as pododermatitis circumscripta or Rusterholz ulcers, are among the most common and economically significant causes of lameness in dairy cattle worldwide. This condition is characterized by a circumscribed lesion at a specific site on the sole, typically located at the junction of the sole and heel on the outer claw of the hind feet. The ulcer develops when the horn-producing tissues of the sole are damaged, resulting in exposure of the underlying sensitive corium and the formation of a painful, often infected lesion. The characteristic location of the ulcer relates to the anatomy of the foot, occurring where the point of the pedal bone, specifically the flexor tuberosity, creates maximum pressure on the sole during weight bearing.

Sole ulcers affect dairy cattle at significantly higher rates than beef cattle, with prevalence estimates ranging from 10 to 30 percent in many dairy herds and even higher in some operations with poor foot health management. The condition is strongly associated with the metabolic and physiological challenges of early lactation, with most cases developing in the first 100 days after calving. The lateral hind claws are most frequently affected, followed by the lateral front claws, reflecting the distribution of weight bearing in dairy cattle. Both first-lactation heifers and older cows are susceptible, though the underlying contributing factors may differ between age groups.

The economic and welfare impact of sole ulcers is substantial and well-documented. Affected cows experience significant pain and lameness that reduces feed intake, milk production, and reproductive performance. Studies have demonstrated milk production losses of 5 to 15 percent in cows with sole ulcers, with effects persisting for weeks to months depending on severity and treatment timing. The cost per case has been estimated at $150 to $500 or more, including direct treatment costs and indirect production losses. Welfare concerns related to the chronic pain of sole ulcers have increasingly focused attention on prevention and early intervention.

Sole ulcers are treatable, and affected cattle can return to full productivity with appropriate management, though outcomes depend heavily on the severity of the lesion at diagnosis and the promptness of intervention. Early-stage ulcers identified during routine hoof trimming often respond well to corrective trimming and therapeutic blocks. Advanced lesions with bone involvement or secondary infection carry guarded prognosis and require more intensive treatment. Prevention through proper nutrition, housing, and hoof care is far more effective and economical than treatment of established lesions.

The primary cause of sole ulcers is localized pressure necrosis of the horn-producing tissues at the typical site where the flexor tuberosity of the pedal bone bears down on the sole. Under normal circumstances, adequate thickness and quality of sole horn provides cushioning that distributes this pressure across a larger area. When the sole horn is thin, soft, or structurally compromised, the concentrated pressure causes ischemia and damage to the corium, disrupting horn production and eventually creating an ulcer. The relationship between internal anatomy and external lesion location is so consistent that sole ulcers are considered a biomechanical disease with a predictable presentation.

Laminitis and subclinical metabolic disturbances are the most important predisposing factors for sole ulcer development. During laminitic episodes, the sensitive laminae that support the pedal bone within the hoof capsule become inflamed and weakened. This allows the bone to sink or rotate within the hoof, increasing pressure on the sole at the typical ulcer site. Simultaneously, horn produced during laminitic periods is softer and less resistant to mechanical stress. The combination of increased bone pressure and weaker horn creates ideal conditions for ulcer formation. Most sole ulcers can be traced back to a metabolic event two to three months before clinical presentation, reflecting the time required for damaged horn to grow down to the weight-bearing surface.

Environmental and management factors contribute significantly to sole ulcer risk by affecting horn quality and mechanical stress on the foot. Housing on hard, abrasive concrete surfaces increases wear on the sole and causes mechanical trauma that damages horn-producing tissues. Extended standing times due to inadequate comfortable lying space, overcrowding, or long waiting times for milking increase the duration of pressure on the soles. Wet, unhygienic conditions soften the horn and increase susceptibility to bacterial invasion. Infrequent or improper hoof trimming allows overgrowth that concentrates weight bearing on the outer claws and the typical ulcer site. Heat stress affects both metabolic function and standing behavior in ways that promote ulcer development.

Risk factors for sole ulcers include several animal-specific and temporal variables. The transition period from late gestation through early lactation represents the highest risk time, with most ulcers becoming clinically apparent 60 to 120 days after calving. First-lactation heifers face elevated risk as their hooves adapt to the demands of adult housing and lactation while still growing. High body weight at calving, particularly in animals that are overconditioned, increases mechanical stress on the soles. The hormonal changes around calving affect connective tissue integrity, including the digital cushion that normally absorbs concussive forces. Genetics influence hoof conformation, including sole thickness and heel depth, affecting susceptibility to ulcer development.

The pathophysiology of sole ulcer development involves progressive tissue damage over weeks to months. Initially, compromised horn produced during a laminitic episode begins growing from the coronary band toward the sole surface. As this weakened horn reaches the weight-bearing area, it provides inadequate protection for the underlying corium. Continued pressure causes compression of blood vessels and ischemic damage to the horn-producing cells. Hemorrhage into the horn may occur, visible as reddish or yellowish discoloration. As damage progresses, the corium becomes exposed through the thinned or absent horn, creating the clinical ulcer. Secondary bacterial infection of the exposed tissues is common and can extend to involve deeper structures including the pedal bone in severe cases.

Early warning signs of sole ulcer development may be detected during routine hoof examination before an obvious lesion is present. Hemorrhage within the sole horn, visible as reddish or yellow-brown discoloration in the typical ulcer location, indicates previous trauma and predicts future ulcer development. Thin sole horn in the affected area, detectable by feel or by visual assessment of horn color changes, suggests increased risk. Subtle gait abnormalities including slightly shortened stride, minor weight shifting, or reluctance on hard surfaces may be present before obvious lameness develops. These early indicators provide opportunities for preventive intervention before a clinical ulcer forms.

Progressive lameness is the most common presenting sign of established sole ulcers. Affected cattle typically show moderate to severe lameness in the affected limb, with the degree of lameness correlating roughly with ulcer severity. The characteristic gait shows a shortened stride on the affected leg and may include head bobbing that rises when the affected leg bears weight. Cattle often place the affected foot carefully and may walk on the inner aspect of the claw to avoid pressure on the outer claw where ulcers most commonly occur. Some animals show arched back posture when standing, reflecting the discomfort of the condition.

Behavioral changes associated with sole ulcers reflect both pain and the adaptive responses cattle make to minimize discomfort. Affected animals typically spend more time lying down and may be reluctant to rise for milking or feeding. Time spent at the feed bunk decreases, leading to reduced feed intake and potential weight loss. Cows with sole ulcers may stand in the stall with only the front of the affected foot touching the floor, resting the heel. Social behavior changes as affected animals become less competitive and may be displaced from preferred feeding or lying positions. Milk production declines both from reduced intake and from the metabolic effects of chronic pain.

Physical examination of the affected foot reveals the characteristic lesion at the typical site. The ulcer typically presents as a circumscribed area of exposed or abnormal tissue at the junction of the sole and heel, usually on the outer claw. Early ulcers show thinning of the horn with discoloration but intact surface. Established ulcers demonstrate exposure of the pink or reddish corium, which may bleed when probed. Granulation tissue may protrude from more chronic lesions, appearing as proud flesh that prevents normal horn regrowth. Secondary infection causes purulent discharge, increased sensitivity, and potentially involvement of deeper structures. The surrounding horn may show underrunning, where the ulcer extends under apparently intact horn.

Symptom progression in untreated sole ulcers follows a predictable pattern of worsening severity and complications. Initial hemorrhage and horn softening progress to exposure of the corium and ulcer formation. Without treatment, the ulcer typically enlarges and deepens as continued pressure prevents healing. Secondary bacterial infection extends the damage to surrounding horn and underlying structures. Severe cases develop involvement of the digital cushion, navicular bursa, or pedal bone, creating deep digital sepsis that significantly worsens prognosis. The affected claw may become severely overgrown as the animal avoids weight bearing, further compounding the problem. Chronic untreated ulcers may eventually develop excessive granulation tissue that interferes with treatment.

Emergency symptoms requiring immediate veterinary intervention include severe non-weight-bearing lameness, evidence of deep infection such as swelling extending above the coronary band, fever or signs of systemic illness, and foul-smelling discharge suggesting necrotic tissue or bone involvement. While uncomplicated sole ulcers are rarely immediately life-threatening, delayed treatment significantly worsens prognosis and increases the risk of complications that may require digit amputation or result in culling. Any sole ulcer that fails to respond to standard treatment or shows signs of deep tissue involvement requires prompt veterinary evaluation.

Clinical examination provides definitive diagnosis of sole ulcers in most cases and guides treatment decisions. Examination begins with observation of gait to assess the degree of lameness and identify the affected limb. The foot is lifted and cleaned thoroughly to allow inspection of the sole surface. The characteristic ulcer at the typical site is usually readily apparent once the foot is cleaned. The examiner assesses the size, depth, and stage of the ulcer, noting whether the corium is exposed, infected, or showing granulation tissue. Probing the lesion carefully evaluates the extent of horn underrunning and potential involvement of deeper structures. Hoof testers may be used to assess sensitivity and identify additional lesion sites.

Diagnostic tests beyond clinical examination are rarely needed for routine sole ulcers but may be indicated in complicated cases. Radiographic examination of the foot can identify bone involvement, including osteitis, osteomyelitis, or fractures of the pedal bone, which significantly affects prognosis and treatment approach. Bacterial culture and sensitivity testing may guide antibiotic selection in cases with severe or unresponsive infection. Blood work can assess for systemic effects of chronic infection or identify concurrent metabolic disease. Histopathological examination is rarely indicated but can differentiate sole ulcers from neoplastic conditions in atypical cases. In research or advanced diagnostic settings, imaging techniques including ultrasound or CT may evaluate soft tissue involvement.

Differential diagnosis for sole ulcers includes other lesions affecting the sole and causing lameness in cattle. Thin soles without ulceration can cause lameness from inadequate cushioning of the pedal bone. Sole hemorrhage without ulceration indicates previous trauma and may precede ulcer development. White line disease affects a different location and typically shows separation along the white line rather than at the typical ulcer site. Sole abscesses cause severe lameness and may have occurred in conjunction with or been mistaken for sole ulcers. Foreign body penetration of the sole causes acute lameness with a different history. Careful examination and knowledge of the characteristic appearance and location of sole ulcers allows confident differentiation.

Herd-level diagnostics become important when sole ulcers affect a significant proportion of the herd. Regular locomotion scoring provides systematic data on lameness prevalence and trends. Recording of lesion types during routine trimming sessions documents sole ulcer incidence and temporal patterns. Analysis of lesion timing relative to calving reveals the typical two to three month lag between metabolic insult and clinical presentation. Nutritional evaluation examines ration composition, feed delivery, and transition cow management for potential improvements. Environmental assessment evaluates flooring, stall comfort, standing times, and other factors influencing lameness risk. Combining individual case data with herd-level analysis allows identification of root causes and guides prevention efforts.

Emergency or immediate treatment for severe sole ulcers focuses on pain relief and protection of the exposed tissues. Non-steroidal anti-inflammatory drugs approved for cattle, such as meloxicam or flunixin meglumine, provide analgesia and should be administered promptly in severely lame animals. Strict adherence to withdrawal times for meat and milk is essential when treating food-producing animals. Moving affected cattle to deep-bedded housing reduces pressure on the damaged sole. If the animal must remain in a hard-floored environment, application of a block to the sound claw provides immediate relief by transferring weight away from the affected claw. Severely affected animals may benefit from being housed separately where they can rest without competition for lying space.

Medical management of sole ulcers centers on corrective hoof trimming and therapeutic blocking. Professional hoof trimming restores appropriate claw balance and removes damaged horn from around the ulcer, promoting drainage and allowing healthy tissue to heal. Trimming reduces the height of the affected claw and may carefully debride the ulcer edges to remove underrun horn. A therapeutic block, typically made of wood, rubber, or acrylic material, is applied to the healthy claw to elevate it and transfer weight bearing away from the ulcerated claw. The block should remain in place for four to six weeks to allow adequate healing time. Topical treatments applied to the ulcer may include antibacterial preparations or dressings, though the evidence for specific topical agents is limited.

Surgical treatment options are reserved for complicated sole ulcers that do not respond to conservative management or have extended to involve deeper structures. Debridement of necrotic tissue and infected bone may be necessary in cases with osteitis or osteomyelitis. Drainage of the navicular bursa or coffin joint may be required if these structures are involved. In severe cases with extensive bone involvement or uncontrollable infection, digit amputation may be performed as a salvage procedure in valuable animals. These surgical interventions carry guarded prognosis and require extended recovery periods. Consultation with a veterinarian experienced in bovine foot surgery is advisable for complicated cases.

Supportive care for sole ulcers emphasizes comfortable housing and attention to factors that promote healing. Deep-bedded housing with ample clean, dry bedding allows affected cows to rest comfortably and reduces pressure on the healing ulcer. Rubber matting in alleys provides cushioning during necessary movement. Nutritional support ensures adequate intake of nutrients for tissue repair, including protein, zinc, copper, and biotin. Reducing competition for feed and lying space allows affected animals to rest and eat without social pressure. Monitoring body condition and milk production helps assess response to treatment and guides decisions about continued management.

Herd treatment protocols for sole ulcers focus on systematic identification and treatment of affected animals and prevention of new cases. Regular locomotion scoring identifies lame cows for examination and treatment. Scheduled hoof trimming programs for all cattle allow early detection of developing lesions before clinical ulcers form. Implementing corrective trimming and blocks for affected animals as soon as lesions are identified improves outcomes. Training staff to recognize early lameness and developing protocols for prompt intervention ensures timely treatment. Addressing environmental and nutritional factors that contribute to sole ulcer development reduces new case incidence.

Treatment decision factors for sole ulcers balance animal welfare, prognosis, and economic considerations. Early-stage ulcers without bone involvement typically respond well to conservative treatment and have good prognosis for return to full production. Moderate ulcers with granulation tissue may require extended treatment but can still achieve good outcomes. Severe ulcers with deep tissue involvement carry guarded prognosis and may require surgical intervention or consideration of culling. Animals with recurrent ulcers may have underlying conformational or metabolic issues that predispose to repeated problems. The stage of lactation, reproductive status, and overall value of the animal influence the intensity of treatment investment.

Recovery timelines for sole ulcers depend significantly on the severity of the lesion at the time of treatment and the presence of complications. Mild ulcers with intact corium or early granulation may show significant improvement within three to four weeks of appropriate treatment. Moderate ulcers with exposed corium but no bone involvement typically require six to eight weeks for adequate healing, with the therapeutic block remaining in place throughout this period. Severe ulcers with bone involvement or deep infection may require three to six months for resolution and may not return to completely normal structure. New horn must grow from the coronary band to replace damaged tissue, which occurs at approximately five millimeters per month.

Post-treatment care and monitoring are essential for successful sole ulcer recovery. The therapeutic block should remain secure throughout the healing period, with checks at regular intervals to ensure it has not loosened or shifted. The cow should be observed for continued lameness, which may indicate block failure or inadequate treatment response. Follow-up examination and trimming at four to six weeks allows assessment of healing progress and adjustment of treatment if needed. Once the block is removed, the healed area should be evaluated and any remaining abnormal horn trimmed. Subsequent trimming sessions should monitor for recurrence at the original site or development of new lesions.

Prognosis factors for sole ulcer recovery include lesion severity, presence of bone involvement, promptness of treatment, and ability to address contributing factors. Early-stage ulcers treated promptly have excellent prognosis for complete resolution. Ulcers with established granulation tissue or mild bone involvement have good prognosis but may show some persistent structural changes. Ulcers with extensive bone involvement, joint involvement, or deep infection have guarded to poor prognosis and may require surgical intervention. The ability to provide adequate treatment, including appropriate blocking and comfortable housing, significantly influences outcomes. Animals in which underlying metabolic or environmental factors cannot be corrected are at risk for recurrence.

Return to production considerations following sole ulcer treatment include monitoring for residual effects and preventing recurrence. Milk production typically improves as lameness resolves, though complete return to pre-lesion production may take several weeks after clinical resolution. Fertility often improves as cows become more active and express normal estrus behavior. Animals should be closely monitored during subsequent trimming sessions for evidence of recurrence or new lesion development. Addressing the nutritional and environmental factors that contributed to the original ulcer is essential for preventing future problems. Cattle with repeated sole ulcer episodes may have conformational predispositions that warrant consideration in breeding decisions.

No vaccines are available for sole ulcer prevention, as the condition is mechanical and metabolic rather than infectious in origin. Prevention efforts focus entirely on management interventions that reduce the incidence of predisposing factors and maintain optimal hoof health. Research continues into nutritional supplements and management strategies that may reduce sole ulcer risk, but currently prevention depends on comprehensive management programs addressing multiple contributing factors. Producers should focus on the modifiable risk factors under their control.

Biosecurity considerations are not directly applicable to sole ulcers, as the condition is not transmissible between animals. However, practices that affect overall herd health influence lameness risk. Controlling infectious diseases that create inflammatory states potentially reduces metabolic triggers for laminar damage. Ensuring purchased animals are evaluated for hoof health identifies problems requiring treatment and prevents introduction of chronically lame animals. Maintaining herd health through appropriate vaccination and disease prevention programs supports overall resilience.

Nutritional prevention of sole ulcers addresses both the metabolic events that predispose to laminar damage and the nutrients required for quality horn production. Formulating rations that minimize ruminal acidosis risk is fundamental, including appropriate effective fiber levels and controlled fermentable carbohydrate content. Gradual dietary transitions during the dry period and early lactation prevent acute metabolic upset. Biotin supplementation at 20 milligrams per head per day has been shown to improve horn quality in multiple studies. Ensuring adequate zinc, copper, manganese, and other trace minerals supports optimal keratinization. Vitamin E and selenium support immune function and tissue integrity. Avoiding excessive body condition at calving reduces metabolic disease risk and mechanical stress on feet.

Management practices for sole ulcer prevention address housing, handling, and hoof care factors that influence foot health. Providing adequate comfortable lying space encourages appropriate resting time and reduces standing on hard surfaces. Stall dimensions should accommodate cattle comfortably, and surfaces should provide cushioning through bedding or mattresses. Rubber flooring in alleys, holding areas, and at feed bunks reduces mechanical trauma to soles. Minimizing time in holding areas before milking reduces standing time. Regular professional hoof trimming, typically twice yearly, maintains appropriate foot balance and identifies developing lesions early. Training staff to recognize lameness and implementing protocols for prompt evaluation and treatment prevents progression of mild problems to severe lesions.

Transition cow management is particularly critical for sole ulcer prevention, as the metabolic events that predispose to ulcers most commonly occur during this period. Comprehensive transition programs that address nutrition, housing, and health monitoring reduce the incidence of metabolic disorders that trigger laminar damage. Providing appropriate dietary adaptation from dry cow through early lactation rations prevents ruminal acidosis. Maintaining adequate body condition without excessive fatness at calving reduces metabolic stress. Close monitoring for periparturient diseases allows early treatment before they trigger widespread metabolic effects. Ensuring adequate space and comfort for transition cows minimizes standing time and mechanical stress on feet during this vulnerable period.

Daily management and monitoring for sole ulcer prevention involves attention to cow behavior, environmental conditions, and early lameness detection. Observing cattle movement during feeding and routine activities identifies animals with developing lameness before severe lesions occur. Monitoring lying times and standing behavior, either through observation or automated sensors, reveals problems with cow comfort that increase sole ulcer risk. Checking that bedding is adequate, dry, and properly maintained ensures comfortable lying areas. Maintaining consistent feeding schedules and monitoring for refusals or sorting helps identify nutritional issues. Recording any lameness observations ensures affected animals receive prompt attention.

Housing and environmental management significantly influence sole ulcer incidence through effects on standing time and mechanical stress. Free stall design should encourage appropriate lying behavior with adequate size, comfortable surfaces, and correct positioning of neck rails and brisket boards. Alley flooring should provide secure footing while minimizing abrasion, with rubber surfacing providing benefits in high-traffic areas. Drainage should prevent water accumulation and wet conditions. Ventilation and cooling systems should manage heat stress, which affects both metabolic function and standing behavior. Holding area time should be minimized through efficient cow flow, and rubber flooring in holding areas provides comfort during necessary standing. Water and feed access should be convenient to minimize walking distances.

Herd health programs for sole ulcer prevention integrate foot health with overall herd management. Regular locomotion scoring provides systematic data on lameness prevalence and allows tracking of trends. Scheduled hoof trimming for all cattle at appropriate intervals maintains foot balance and identifies developing lesions. Transition cow protocols should specifically address sole ulcer risk factors. Lameness investigation protocols ensure affected animals receive prompt evaluation and treatment. Staff training in lameness recognition and reporting improves early detection. Integration of foot health goals with reproduction, production, and culling decisions ensures comprehensive management.

Record keeping and monitoring provide the foundation for effective sole ulcer prevention programs. Individual animal records should document lameness episodes, lesions identified at trimming, and treatments provided. Tracking lesion occurrence relative to calving date reveals the expected two to three month lag between metabolic insult and clinical presentation. Production data correlated with lameness records demonstrates the economic impact and guides resource allocation. Herd-level summaries of lesion types and trends over time measure program effectiveness. Benchmarking against other operations and published standards identifies opportunities for improvement.

Economic considerations for sole ulcer management strongly favor prevention over treatment. The costs of clinical sole ulcers, including treatment, milk loss, reproductive impacts, and premature culling, have been estimated at $150 to $500 or more per case. Prevention investments including improved housing, regular trimming, and enhanced transition cow management typically provide positive returns. Rubber flooring installation represents a capital expense with ongoing benefits through reduced lameness. Professional hoof trimming costs are offset by reduced treatment needs and improved productivity. Cost-benefit analysis of specific interventions guides resource allocation toward the most effective prevention strategies.

High-risk breeds for sole ulcers include dairy breeds managed under intensive production systems, with Holstein-Friesians being most frequently affected due to their predominance in modern dairy operations. The high metabolic demands of Holsteins selected for maximum milk production, combined with typical housing and management systems, create conditions favorable for sole ulcer development. Other dairy breeds including Jersey, Brown Swiss, and Ayrshire cattle also experience sole ulcers, though comparative prevalence data is limited. Beef cattle rarely develop classical sole ulcers due to their less intensive management and lower metabolic stress, though the condition can occur in feedlot settings.

Production type considerations strongly influence sole ulcer risk. High-producing dairy cows face the greatest risk due to the metabolic challenges of supporting substantial milk output, particularly during negative energy balance in early lactation. First-lactation heifers experience elevated rates as they adapt to adult housing while still growing. Cows that calve in overconditioned state may be at increased risk due to metabolic disease susceptibility. The timing of maximum risk corresponds to peak lactation and the associated metabolic demands. Production intensity and associated management practices significantly influence herd-level prevalence.

Genetic selection considerations for sole ulcers include both direct selection for hoof health and indirect effects through production traits. Hoof conformation, including sole thickness, heel depth, and claw angle, has moderate heritability and influences sole ulcer susceptibility. Some breeding organizations now include hoof health in genetic evaluations, allowing producers to select bulls with favorable foot trait profiles. Selection for extreme milk production without attention to metabolic efficiency and structural soundness may indirectly increase sole ulcer risk. Balanced breeding goals that include foot health alongside production traits support long-term herd sustainability. Recording of hoof lesions during trimming provides data for genetic evaluation when combined with pedigree information.

Commonly co-occurring conditions with sole ulcers include other lameness-causing hoof lesions that share underlying risk factors. White line disease frequently occurs in the same animals and herds as sole ulcers, as both conditions relate to compromised horn quality and laminar damage. Heel erosion is often concurrent, sharing environmental risk factors including wet conditions and hard flooring. Digital dermatitis may be present on feet affected by sole ulcers, creating compound lesions requiring comprehensive treatment. Laminitis is the underlying condition that predisposes to sole ulcer development, and evidence of laminitic changes is often visible on affected and contralateral feet. Sole hemorrhage without ulceration represents an earlier stage of the same pathological process.

Conditions with similar symptoms to sole ulcers require differentiation for appropriate treatment. White line disease causes lameness and sole lesions but occurs at a different location along the white line rather than the typical ulcer site. Sole abscesses cause severe, often acute lameness with different history and examination findings. Foreign body penetration of the sole may cause similar pain but has distinct history and lesion characteristics. Toe ulcers occur in a different location and have somewhat different etiology. Thin soles without ulceration cause lameness through inadequate cushioning rather than exposed corium. Careful examination and knowledge of the characteristic location and appearance of sole ulcers allows accurate differentiation.

Complications and sequelae of sole ulcers extend the condition's impact and worsen prognosis. Secondary bacterial infection of exposed corium commonly occurs and can extend to deeper structures. Deep digital sepsis involving the pedal bone, navicular bursa, or coffin joint carries guarded to poor prognosis and may require surgical intervention or digit amputation. Excessive granulation tissue formation can prevent normal healing and requires debridement. Chronic sole ulcers may lead to permanent structural changes in the affected claw. Compensatory weight shifting to other limbs can cause secondary problems in those feet. Reduced production, impaired fertility, and shortened productive lifespan represent the cumulative consequences of sole ulcers and their complications.