Introduction and objective:
Diabetes-related lower limb complications, including diabetic foot ulcers, peripheral artery disease, critical limb ischaemia, and neuropathic pain, are public- and occupational-health concerns, as chronic wounds, impaired mobility, and amputation risk, reduce independence and work capacity. Despite advances in revascularization and wound care, options for advanced ischaemia, particularly ‘no-option’ critical limb ischaemia, remain limited. The aim of the review is to evaluate botulinum toxin type A (BoNT-A) as an adjunctive strategy targetting microcirculatory dysfunction, pain, and biomechanical overload.

Review methods:
A narrative review was conducted using PubMed, Scopus, and Google Scholar. The search included ‘botulinum toxin’, ‘diabetes’, ‘diabetic foot’, ‘ischaemia, ‘PAD’, ‘angiopathy’, and ‘sympathectomy’, with emphasis on peer-reviewed clinical and experimental studies.

Brief description of the state of knowledge:
Evidence suggests that BoNT-A may improve local perfusion through reversible chemical sympathectomy and norepinephrine-release inhibition, promoting vasodilation and microcirculatory flow. It may also reduce neuropathic and ischaemic pain by modulating substance P and CGRP release, and decrease plantar overload through muscle relaxation. These mechanisms are relevant to diabetic foot ulcers, painful diabetic neuropathy, and critical limb ischaemia. However, available data remain heterogeneous and limited by small cohorts, non-standardized protocols, and lack of randomized trials.

Summary:
BoNT-A should not be regarded as a replacement for established diabetic foot care, revascularization, infection control, or offloading. Nevertheless, it may represent a promising adjunctive approach for selected high-risk patients when conventional options are limited. Randomized studies are needed before broader clinical implementation can be recommended.