**4. Vascular disease**

Gangrene in diabetics is primarily vascular problem. Arterial disease can aggravate most other diabetic foot problems. Vascular evaluation is recommended in patients

*Tendon Balancing for Diabetic Foot Ulcers, Foot Pain and Charcot Foot DOI: http://dx.doi.org/10.5772/intechopen.105938*

without pedal pulses. Patients with palpable dorsalis pedis or posterior tibial arteries require no additional studies. Arterial Doppler is recommend for patients without both of those pedal pulses. Ankle-brachial index (ABI) has been used by others for lower extremity arterial evaluation. The ABI is calculated by dividing systolic pressure at the ankle by that at the arm. An abnormal ABI is 0.90 or below [50]. Vascular surgery evaluation should be obtained If the Doppler study shows near or complete blockage or if ABI is abnormal.

Vascular disease has been considered to be a contraindication to TCC [45]. Foot ulcers in patients without both pedal pulses can be salvageable with tendon lengthening [26, 29, 34].
