Diabetes mellitus affects far more than blood glucose levels. Over time, persistently elevated blood glucose can damage nerves and blood vessels throughout the body, with the feet being particularly vulnerable. A minor blister, crack or cut that would normally heal without difficulty can progress into infection, ulceration and, in severe cases, amputation. Many of these complications are preventable. For this reason, daily foot care, appropriate footwear, regular professional assessment and effective diabetes management are essential parts of protecting the health, mobility and independence of people with diabetes.
One of the most important threats to diabetic foot health is peripheral neuropathy. Prolonged hyperglycaemia can injure the nerves supplying the feet, reducing the ability to feel pain, pressure, heat and cold. This loss of protective sensation means that a person may not notice a sharp object inside a shoe, a blister caused by friction, a burn from hot water or a wound sustained while walking barefoot. Because pain normally warns people to stop an activity and examine an injury, diminished sensation allows tissue damage to continue. Neuropathy may also contribute to foot deformities. These can concentrate pressure on small areas, increasing the likelihood of callus formation and ulceration.
Diabetes can also reduce circulation. Peripheral arterial disease occurs when arteries supplying the legs and feet become narrowed, commonly through atherosclerosis. Smoking, high blood pressure and abnormal cholesterol levels can compound this risk. Poor blood flow deprives damaged tissues of oxygen, nutrients and immune cells, making wounds slower to heal and infections more difficult to overcome. Typical warning signs may include pain in the calves during walking, cold feet, changes in skin colour or wounds that fail to heal. However, neuropathy can mask discomfort, so serious circulatory disease may be present without obvious pain. This combination of impaired sensation and impaired healing makes apparently insignificant injuries potentially dangerous.
A diabetic foot ulcer often develops through a chain of events rather than a single dramatic injury. Repeated pressure or rubbing may produce a callus, beneath which tissue becomes inflamed and breaks down. Alternatively, a small cut, cracked heel or poorly trimmed nail may provide an entry point for bacteria. If the person cannot feel the injury, it may remain untreated while walking continues to stress the area. Infection can then spread into deeper tissues or bone. Diabetic foot ulcers are associated with hospital admission, prolonged treatment and a substantial risk of lower-limb amputation. They can also restrict work, exercise and social participation. Prevention is therefore safer than treating an advanced wound.
Daily inspection is a simple but powerful preventive measure. A person with diabetes should examine the tops, soles, heels, sides and spaces between the toes every day, using a mirror or assistance from another person if necessary. They should look for cuts, blisters, redness, swelling, calluses, cracks, discharge, colour changes and nail problems. Feet should be washed in lukewarm—not hot—water, dried carefully, especially between the toes, and moisturised to reduce dry, cracked skin. Moisturiser should not be placed between the toes because excess moisture there can encourage fungal infection. Corns and calluses should never be cut away at home or treated with acidic over-the-counter preparations; these can damage healthy skin and should instead be assessed by a suitably qualified clinician.
Nail and skin care also require caution. Toenails should generally be trimmed straight across and filed to remove sharp edges, provided the person can see and reach the feet safely and has no major circulatory, sensory or nail problems. People who have poor vision, reduced sensation, thickened nails, previous ulcers or uncertainty about self-care should seek professional help. Walking barefoot, even indoors, increases the risk of unnoticed punctures, burns and cuts. Before putting on shoes, the inside should be checked for stones, rough seams or folded insoles. Socks should be clean, well fitting and free from constrictive bands.
Appropriate footwear helps distribute pressure and protects the feet from trauma. Shoes should fit the length, width and depth of the foot without squeezing the toes or rubbing prominent areas. New footwear should be worn for short periods initially and the feet checked afterward for redness or blistering. People with deformity, severe neuropathy or previous ulceration may require therapeutic footwear or pressure-relieving insoles. Footwear cannot compensate for an untreated wound: hot, swollen or broken skin requires prompt assessment and may require specialised offloading.
Regular clinical screening identifies risk before a crisis develops. Diabetes reviews should include examination of the skin and nails, assessment of foot shape and footwear, testing for protective sensation, and evaluation of circulation. Follow-up should reflect the person’s risk. Neuropathy, arterial disease, deformity, kidney disease or a previous ulcer or amputation require closer surveillance. Podiatrists, diabetes clinicians, nurses and vascular specialists may contribute to multidisciplinary care.
Good general diabetes management is equally important. Keeping blood glucose within an individually agreed target can reduce the progression of nerve and vascular damage. Controlling blood pressure and cholesterol, avoiding tobacco, maintaining appropriate physical activity and attending regular health reviews further protect circulation and healing. Exercise is valuable, but activities and footwear should be chosen carefully when sensation is reduced or an ulcer is present. Education should be practical and repeated because circumstances and risk can change over time.
Certain warning signs demand urgent attention. A new ulcer, spreading redness, swelling, pus, unpleasant odour, blackened skin, fever or a foot that suddenly becomes hot or changes shape should not be managed by simply “waiting to see.” Prompt medical or podiatric assessment can prevent infection and tissue damage from progressing. Even a painless wound can be serious in a person with neuropathy.
People with diabetes must take particular care of their feet because nerve damage can hide injury while poor circulation can delay healing. Pressure, minor trauma and infection may then combine to produce ulceration and possible amputation. Daily inspection and hygiene, safe nail and skin care, protective well-fitting footwear, regular professional screening and good management of diabetes and cardiovascular risks form an effective prevention strategy. Consistent attention to small changes can preserve not only the feet, but also a person’s mobility, confidence, independence and quality of life.
References
American Diabetes Association Professional Practice Committee. (2024). Retinopathy, neuropathy, and foot care: Standards of Care in Diabetes—2024. Diabetes Care, 47(Supplement 1), S231–S243.
International Working Group on the Diabetic Foot. (2023). IWGDF guidelines on the prevention and management of diabetes-related foot disease. https://iwgdfguidelines.org/
National Institute for Health and Care Excellence. (2019, updated 2023). Diabetic foot problems: Prevention and management (NG19). https://www.nice.org.uk/guidance/ng19
World Health Organization. (2023). Diabetes. https://www.who.int/news-room/fact-sheets/detail/diabetes