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INTRODUCTION

Over time, diabetes can lead to various complications, many of which can be serious if they are not identified and addressed promptly. Foot problems are a common complication in people with diabetes.

In general, you can lower your risk of diabetes-related complications by keeping your blood sugar in the goal range and seeing your doctors for regular checkups. You can also lower your risk of developing foot problems by examining your feet regularly. This way, if problems do occur, you are more likely to notice them right away so you can get the proper treatment. It may take time and effort to build good foot care habits, but it is an essential part of diabetes management.

This article will discuss the foot-related complications that can happen in people with diabetes, as well as guidelines for good foot care and tips for lowering your risk of developing these problems. Other diabetes-related complications are discussed separately. (See "Patient education: Preventing complications from diabetes (Beyond the Basics)" .)

RISK FACTORS

Over time, diabetes that is not carefully managed can lead to foot complications. You have an increased risk of developing foot problems if you have:

● A past foot ulcer

● Nerve damage

● Foot deformities

● Poor circulation

If you have any of these risk factors (discussed in more detail below), particularly a previous foot ulcer, you may be at increased risk of foot problems if you take medications called sodium-glucose co-transporter 2 (SGLT2) inhibitors to manage your blood sugar. SGLT2 inhibitors, particularly canagliflozin, may increase your risk of requiring toe amputations. Your health care provider can talk to you about other medication options.

Past foot ulcer  —  Once you have had a foot ulcer, even if it heals completely, you are at an increased risk of developing ulcers again in the future.

Nerve damage  —  Over time, high blood sugar levels can damage the nerves that carry sensation; this nerve damage is known as "diabetic neuropathy." Because people with neuropathy may lose their ability to sense pain, they are at increased risk for injuring their feet; even a minor injury can become serious quickly if it goes unnoticed. Nerve damage can also weaken certain foot muscles and contribute to foot deformities. (See 'Signs of nerve damage' below and "Patient education: Diabetic neuropathy (Beyond the Basics)" .)

Foot deformity  —  Abnormalities in the shape of the toes, arches, or bottoms of the feet can raise the risk of complications. (See 'Deformities' below.)

Poor circulation  —  Longstanding high blood sugar levels can cause damage to the blood vessels, decreasing blood flow to the feet. Smoking can also worsen blood vessel damage and reduce blood flow. Poor circulation can weaken the skin, contribute to the formation of foot ulcers, and impair wound healing. Some bacteria and fungi thrive on high levels of sugar in the bloodstream; if a wound gets infected, this can break down the surrounding skin and make ulcers worse. (See 'Signs of poor circulation' below.)

More serious complications include deep skin and bone infections. Gangrene (decay and death of tissue) is a very serious complication; widespread gangrene may require amputation. Approximately 5 percent of people with diabetes eventually require amputation of a toe or foot. However, this can be prevented in most situations by managing blood sugar levels, quitting smoking if you smoke, and committing to daily foot care.

FOOT EXAMINATIONS

Regular foot exams to check for problems or changes are a critical part of managing your diabetes.

Self-exams  —  It is important to examine your feet every day, especially if you have any of the major risk factors for foot problems. This should include looking carefully at all parts of your feet, especially the area between the toes. Look for broken skin, ulcers, blisters, areas of increased warmth or redness, or changes in callus formation; let your health care provider know if you notice if any of these changes or have any concerns. (See 'Risk factors' above.)

It may help to make the foot exam a part of your daily bathing or dressing routine. You might need to use a mirror to see the bottoms of your feet clearly. If you are unable to reach your feet or see them completely, even with a mirror, ask another person (such as a family member) to help you.

Clinical exams  —  During your routine medical visits, your health care provider will check the blood flow and sensation in your feet. The frequency of these clinical exams will depend on which type of diabetes you have:

● In people with type 1 diabetes , annual foot exams should begin five years after diagnosis.

● In people with type 2 diabetes , annual foot exams should begin at the time of diagnosis.

During a foot exam, your health care provider will check for poor circulation, nerve damage, skin changes, and deformities. They will also ask you about any problems you have noticed in your feet. An exam can check for decreased or absent reflexes or decreased ability to sense pressure, vibration, pin pricks, and changes in temperature.

Special devices, including a monofilament or tuning fork, can help determine the extent of nerve damage. A monofilament is a very thin, flexible thread that is used to determine if you are able to sense pressure in different parts of the foot. A tuning fork is used to determine if you can sense vibration in different areas, especially the foot and toe joints.

What to look for  —  You and your health care provider can look for certain signs and symptoms that could indicate problems with your feet.

Skin changes or wounds  —  Excessive skin dryness, scaling, and cracking may be signs of problems. Other skin changes to look for include calluses, broken skin between the toes, and ulcers. Ulcers can start out as sores affecting just the top layer of skin ( picture 1 ), but if left untreated, they can go deeper into the skin and muscle.

Signs of nerve damage  —  Nerve damage may lead to unusual sensations in the feet and legs, including pain, burning, tingling, or numbness. If you notice these symptoms, keep track of when they happen; whether your feet, ankles, and/or calves are affected; and what measures relieve the symptoms.

Over years, if nerve damage becomes advanced, the foot and leg can eventually lose sensation completely. This can be very dangerous because if you cannot feel pain, you may not notice if your shoes do not fit properly, if you have something in your shoe that could cause irritation, or if you have injured your foot.

Deformities  —  The structure and appearance of the feet and foot joints can indicate diabetes-related complications. Nerve damage can lead to joint and other foot deformities. The toes may have a peculiar "claw toe" appearance ( picture 2 ), and the foot arch and other bones may appear collapsed. This destruction of the bones and joints is called "Charcot arthropathy" ( picture 3 ).

Signs of poor circulation  —  A weak pulse, cold feet, thin or blue skin, and lack of hair in the area suggest that your feet are not getting enough blood flow.

PREVENTING FOOT PROBLEMS IN DIABETES

There are several things you can do to reduce your chances of developing foot problems. In addition to managing your blood sugar, practicing good foot care habits and checking your feet daily are important for preventing complications.

Avoid activities that can injure the feet  —  Certain activities increase the risk of foot injury or burns and are not recommended. These include walking barefoot (since you could step on something without realizing it), using a heating pad or hot water bottle on your feet, and stepping into a hot bath before testing the temperature.

Use care when trimming the nails  —  Trim your toenails straight across, and avoid cutting them down the sides or too short ( figure 1 ). You can use a nail file to remove any sharp edges to prevent the toenail from digging into your skin. Never cut your cuticles or allow anyone else (eg, a manicurist) to do so. See a foot care provider (such as a podiatrist) if you need treatment for an ingrown toenail or callus.

Wash and check your feet daily  —  Use lukewarm water and mild soap to clean your feet. Thoroughly dry your feet, paying special attention to the spaces between the toes, by gently patting them with a clean, absorbent towel. Apply a moisturizing cream or lotion.

Check the entire surface of both feet for skin breaks, blisters, swelling, or redness, including between and underneath the toes where damage may not be easily visible. Do not pop blisters or otherwise break the skin on your feet. Let your health care provider know right away if you notice any changes or problems. (See 'Self-exams' above.)

Choose socks and shoes carefully  —  Wear wool or cotton socks that fit well, and be sure to change your socks every day. Select shoes that are snug but not tight, with a wide toe box ( figure 2 ), and break new shoes in gradually to prevent any blisters. It may be helpful to rotate several different pairs of comfortable, well-fitting shoes to avoid consistent pressure on one part of your foot. If you have foot deformities or ulcers, ask your foot care provider about customized shoes; this can reduce your chances of developing foot ulcers in the future. Shoe inserts may also help cushion your step and decrease pressure on the soles of your feet.

Be sure to get regular foot exams  —  Checking for foot-related complications should be a routine part of most medical visits; however, this is sometimes overlooked. Don't hesitate to ask your provider for a foot check at least once a year, or more frequently if you have risk factors or notice any changes. (See 'Clinical exams' above and 'Risk factors' above.)

Quit smoking  —  Smoking can worsen heart and circulation problems and reduce circulation to the feet. If you smoke, quitting is one of the most important things you can do to improve your health and reduce your risk of complications. While this can be difficult, your health care provider can help you and provide other resources for support. (See "Patient education: Quitting smoking (Beyond the Basics)" .)

Walk regularly  —  Regular walking helps improve blood flow in people with poor circulation. "Claudication" refers to pain, cramping, fatigue, or discomfort in the thighs or legs that occurs with walking and improves with rest. If you have symptoms of claudication, walk until the pain or discomfort becomes moderate, then rest, and start walking again, aiming to walk for 30 minutes. Of course, walking 30 minutes daily is good for your overall health as well.

Importance of blood sugar management  —  In general, you can reduce your risk of all diabetes-related complications, including foot problems, by keeping your blood sugar levels as close to your target as possible. Careful management of blood sugar levels can reduce the risk of circulation problems and nerve damage that often lead to foot complications.

Managing your blood sugar requires seeing your doctor regularly, making healthy diet and lifestyle changes, and taking your medications as directed. More information about managing your diabetes is available separately. (See "Patient education: Type 1 diabetes: Insulin treatment (Beyond the Basics)" and "Patient education: Type 2 diabetes: Treatment (Beyond the Basics)" and "Patient education: Glucose monitoring in diabetes (Beyond the Basics)" and "Patient education: Preventing complications from diabetes (Beyond the Basics)" .)

TREATMENT OF FOOT ULCERS

If you do get a foot ulcer, the treatment will depend on how deep the ulcer extends beneath the skin.

Superficial ulcers  —  Superficial ulcers involve only the top layers of skin ( picture 1 ). Treatment usually includes cleaning the ulcer and removing dead skin and tissue by a health care provider; this is called "debridement." It often involves using a scalpel or scissors, although different providers use different techniques. After debridement, the area is covered with a dressing to keep it clean and moist.

If the foot is infected, you will get antibiotics. You should clean the ulcer and apply a clean dressing twice daily or as instructed by your foot care provider; you may need to have someone help you with this. Keep weight off the affected foot as much as possible and elevate it when you are sitting or lying down. Depending on the location of the ulcer, you might also get a cast or other device to take pressure off the area when you walk. Your health care provider should check your ulcer at least once per week to make sure that it is healing properly.

More extensive ulcers  —  Ulcers that extend into the deeper layers of the foot, involving muscle and bone ( picture 4 ), usually require treatment in the hospital. Laboratory tests and X-rays may be done, and intravenous (IV) antibiotics are often given. In addition to debridement to remove dead skin and tissue, surgery may be necessary to remove infected bone. You may also get something called "negative pressure wound therapy"; this involves covering the ulcer with a bandage and using a special vacuum device to help increase blood flow and speed healing.

If part of the toes or foot becomes severely damaged, causing areas of dead tissue (gangrene), partial or complete amputation may be required. Amputation is reserved for wounds that do not heal despite aggressive treatment, or times when health is threatened by the gangrene. Untreated gangrene can be life threatening.

Some people with severe foot ulcers and peripheral vascular disease (poor circulation) may require a procedure to restore blood flow to the foot. (See "Patient education: Peripheral artery disease and claudication (Beyond the Basics)" .)

While foot problems in diabetes are common and can be serious, keep in mind that there are things you can do to help prevent them. Quitting smoking, if you smoke, is one of the most important things you can do for your overall health and to prevent foot problems. In addition, while daily self-care can be challenging, managing your diabetes from day to day, including foot care, is the best way to reduce your risk of developing complications. (See 'Preventing foot problems in diabetes' above.)

WHERE TO GET MORE INFORMATION

Your health care provider is the best source of information for questions and concerns related to your medical problem.

A booklet on foot care for people with diabetes can be found at https://www.govinfo.gov/app/details/GOVPUB-HE20-PURL-gpo118664 .

This article will be updated as needed on our website ( www.uptodate.com/patients ). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information  —  UpToDate offers two types of patient education materials.

The Basics  —  The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Foot care for people with diabetes (The Basics) Patient education: Type 2 diabetes (The Basics) Patient education: Nerve damage caused by diabetes (The Basics) Patient education: The ABCs of diabetes (The Basics) Patient education: Gangrene (The Basics) Patient education: Diabetes and infections (The Basics) Patient education: Diabetic foot ulcer (The Basics)

Beyond the Basics  —  Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Type 1 diabetes: Overview (Beyond the Basics) Patient education: Exercise and medical care for people with type 2 diabetes (Beyond the Basics) Patient education: Type 2 diabetes: Overview (Beyond the Basics) Patient education: Hypoglycemia (low blood glucose) in people with diabetes (Beyond the Basics) Patient education: Preventing complications from diabetes (Beyond the Basics) Patient education: Diabetic neuropathy (Beyond the Basics) Patient education: Glucose monitoring in diabetes (Beyond the Basics) Patient education: Quitting smoking (Beyond the Basics) Patient education: Peripheral artery disease and claudication (Beyond the Basics)

Professional level information  —  Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Screening for diabetic polyneuropathy Evaluation of the diabetic foot Management of diabetic foot ulcers

The following organizations also provide reliable health information.

● National Library of Medicine

( www.nlm.nih.gov/medlineplus/healthtopics.html )

● National Institute of Diabetes and Digestive and Kidney Diseases

( www.niddk.nih.gov )

● American Diabetes Association (ADA)

(800)-DIABETES (800-342-2383)

( www.diabetes.org )

● The Endocrine Society

( www.endo-society.org )

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Your Guide to Diabetes Foot Care

Why is foot care important?

If you have diabetes, nerve damage, circulation problems, and infections can lead to serious foot problems. However, you can take precautions to maintain healthy feet.

Managing your diabetes and maintaining a healthy lifestyle helps keep your feet healthy. This should include:

• regular medical exams, including foot checks once a year and checking your ABCs (A1c, blood pressure, and cholesterol)
• monitoring your blood sugar daily
• regular exercise
• eating a balanced diet rich in fruits and vegetables

You can help prevent serious foot problems by following a good foot care regimen.

Daily foot care

Here are a few foot care habits you can adopt and try to do every day.

1. Inspect your feet

Check your feet and toes, inspecting the tops, sides, soles, heels, and the area in between the toes. If you’re physically unable to inspect your own feet, use a mirror or ask someone to help. Contact your doctor immediately if you discover any sores, redness, cuts, blisters, or bruises.

2. Wash your feet

Wash your feet every day in warm water with mild soap. Hot water and harsh soaps can damage your skin. Check the water temperature with your fingers or elbow before putting your feet in. Your diabetes may make it difficult to sense water temperature with your feet.

3. Dry your feet

Pat your feet to dry them and make sure to dry well. Infections tend to develop in moist areas, so make sure you dry the area between your toes well.

4. Moisturize dry skin

If the skin on your feet feels rough or dry, use lotion or oil. Do not use lotion between your toes.

Healthy foot habits

Following good foot care habits will go a long way toward keeping your feet healthy. Here are a few helpful tips.

• Antiseptic solutions can burn your skin. Never use them on your feet without your doctor’s approval.
• Never use a heating pad, hot water bottle, or electric blanket on your feet.
• Avoid walking barefoot. Most people know to avoid hot pavement or sandy beaches, but even walking barefoot around the house can cause sores or injuries that can get infected.
• Protect your feet from heat and cold.
• Never attempt to remove corns, calluses, warts, or other foot lesions yourself. Don’t use chemical wart removers, razor blades, corn plasters, or liquid corn or callus removers. See your doctor or podiatrist.
• Don’t sit with your legs crossed or stand in one position for long periods of time.

Toenail care

It’s possible for people with diabetes to perform routine toenail care. But visual difficulty, nerve problems, or circulatory changes in the legs or feet can make this unsafe.

If you’re able to safely trim your toenails yourself, doing so properly will help you avoid getting an ulcer or foot sore. Make sure to consult with your healthcare provider to see if it’s safe for you to perform routine toenail care. Ask them to show you the correct way.

Here are a few tips for proper toenail care:

• Trim your toenails after washing your feet, when your nails are soft.
• Cut straight across rather than in a curved fashion to help prevent ingrown toenails.
• Don’t cut into the corners. Use an emery board to smooth the edges.
• Be careful not to cut toenails too short.
• Have your toenails trimmed by a foot doctor or another healthcare provider if you can’t see well, or if your nails are thick or yellowed.

If you have neuropathy, or nerve damage that has affected foot sensitivity, you may overlook cuts or bumps. You can help protect your feet by wearing shoes at all times.

• Choose comfortable, well-fitting shoes with plenty of room, especially in the toe box. Never buy tight shoes hoping they will stretch.
• Do not wear shoes made out of plastic or other materials that do not breathe. Choose leather, canvas, or suede.
• Avoid thong sandals, flip-flops, pointed-toe and open-toe shoes, and very high heels.
• Wear shoes that can be adjusted with laces, buckles, or Velcro.
• Inspect the inside of your shoes every day for tears or bumps that may cause pressure or irritation.
• If you have nerve damage, give your feet a break or change shoes after five hours to change the pressure points on different areas of your feet.
• If you experience repeated problems with your feet, ask your doctor if special shoes would help.
• Socks can provide an extra layer of soft protection between your foot and your shoe.
• Wear clean, dry socks, or non-binding pantyhose. Avoid socks or hosiery with seams that can cause additional pressure points or are too tight on the leg.
• Wear socks to bed if your feet are cold.

Signs and symptoms of foot problems

It’s important to recognize early warning signs of foot problems, such as:

• burning, tingling, or painful feet
• loss of sensation to heat, cold, or touch
• changes to the color or shape of your feet
• loss of hair on the toes, feet, and lower legs
• thickening and yellowing of the toenails
• onset of red spots, blisters, sores, ulcers, infected corns, or ingrown toenails

If you have any of these symptoms, call your doctor immediately. Delay may result in serious health complications.

Potential complications

Following the tips above can help you to avoid foot problems. As stated above, high blood sugar levels over time can cause nerve damage and circulation problems. These problems can cause or contribute to foot problems. Left unnoticed or untreated, sores, ingrown toenails, and other problems can lead to infection. Poor circulation makes healing an infection difficult. So it’s best to avoid them if possible.

Infections that do not heal can cause skin and tissue to die and turn black. This is called gangrene. Treatment can involve surgery to amputate a toe, foot, or part of a leg.

Visiting the doctor

A doctor should examine your feet at every visit and do a thorough foot exam once a year. If you have a history of foot problems, you should be checked more often. Your health care provider should also give you information on foot care and answer all your questions. Report any corns, calluses, sores, cuts, bruises, infections, or foot pain.

If necessary, your doctor can recommend a podiatrist who specializes in diabetic foot care or give you information about special shoes that may help.

Remember: Diabetes-related foot problems can worsen very quickly and are difficult to treat, so it’s important to seek prompt medical attention.

How we reviewed this article:

• American Diabetes Association Professional Practice Committee. (2022). Retinopathy, neuropathy, and foot care: Standards of medical care in diabetes. https://diabetesjournals.org/care/article/45/Supplement_1/S185/138917/12-Retinopathy-Neuropathy-and-Foot-Care-Standards
• Diabetes and foot problems. (2017). https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/foot-problems
• Diabetes and your feet. (2023). https://www.cdc.gov/diabetes/library/features/healthy-feet.html
• Diabetes foot complications. (n.d.). https://diabetes.org/diabetes/foot-complications

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• Continuing Education Activity

Proper diabetic foot care is an essential part of limb preservation. Patients with diabetes are at increased risk for foot ulceration secondary to neuropathy, microvascular disease, and biomechanical/anatomical changes. The following activity will provide an overview of performing a proper diabetic foot exam, frequency of visits, anatomical changes of the diabetic foot, special equipment needed, unique disease processes associated with diabetic foot, and the difference healthcare specialties involved in providing care.

• Identify the critical anatomical structures, conditions, indications, and contraindications for diabetic foot care.
• Describe the equipment, personnel, preparation, and technique in regards to diabetic foot care.
• Review the possible complications of poor diabetic foot care.
• Outline interprofessional team strategies for improving care coordination and communication to advance diabetic foot care and improve outcomes.
• Introduction

Diabetes mellitus is a metabolic disease resulting in increased glucose in the bloodstream. Estimates are that there are 451 million individuals with diabetes worldwide and approximately 5 million diabetes-related deaths in 2017 globally. [1]   

Patients with diabetes mellitus are at increased risk for pedal ulceration due to microvascular, neuropathic, and biomechanical changes to the foot. Neuropathic changes to the body result in decreased pedal sensation and make the diabetic foot prone to wounds from pressure, mechanical, or pressure injuries. Microvascular changes can result in reduced blood flow to the lower extremity, and delaying healing of wounds.

Hemoglobin A1c is a marker that reflects average blood glucose levels over a 2 to 3 month period. The American Diabetes Association and International Expert Committee agree that a hemoglobin A1c greater than or equal to 6.5% is the recommended level for the diagnosis of diabetes. [2]  An increase in HgA1c of 1% has demonstrated to increase peripheral vascular disease risk by 25 to 28% [3] .

Patients with diabetes are at high risk for lower extremity amputations, higher healthcare costs, and lower quality of life. In a systematic regarding non-traumatic amputations of patients with diabetes mellitus and peripheral vascular disease, the 5-year mortality rate of patients after a below-the-knee amputation was 40 to 82%, and mortality after an above-the-knee amputation was 40 to 90%. [4] [3]  Many of these complications are preventable by a thorough annual foot exam and routine foot care performed by the patient.

The purpose of this article is to discuss anatomy, indications, equipment, personnel, preparation, technique, complications, and clinical significance of the diabetic foot.

• Anatomy and Physiology

The diabetic foot differs from a normal foot in several ways. Changes to the diabetic foot include musculoskeletal, dermatologic, vascular, and neurological etiologies.

In the musculoskeletal system, a decrease in intrinsic musculature, limited joint mobility, changes in foot type, and ankle equinus, and others all occur in the diabetic foot. 

Limited joint mobility of the first metatarsophalangeal joint (hallux limitus) is often present in patients with diabetes, which can be caused by a thickening of the Achilles tendon and plantar fascia. This thickening of the plantar fascia and Achilles tendon leads to a more rigid foot type, increased pes planus, and possible unsteadiness of gait. [5]  

The pedal musculature becomes disorganized and infiltrated with adipose tissue as a result of long-standing diabetes. Intrinsic pedal muscles become weaker than extrinsic muscles resulting in foot deformities such as hammertoes or claw toe deformities. [5]   

Hammertoes and claw toes along with hallux limitus correlated with increased risk for ulcer occurrence. Bus et al. studied elevated plantar pressures in patients with diabetes with hammer and claw toes and found that plantar metatarsal head pressures significantly increased with increasing toe deformity. They noted that there is a transfer of load from distal to proximal in such toe deformities, with possible distal fat pad displacement as a mechanism. [6]

Searle et al. found that patients with diabetes have a high rate of ankle equinus, defined as less than 5 degrees of ankle dorsiflexion. This condition has correlations with increased forefoot pressure and tissue breakdown, both barefoot and with shoegear. [7]

Dermatologic integrity is one of the most important functions of human skin, but as a result of chronic diabetes, many changes put this critical organ at risk. Autonomic dysfunction as a result of diabetes decreases perspiration in the foot, which leads to increased fissuring and xerosis. [8]  

Repetitive stress and pressure to one area, in conjunction with neuropathy, causes inflammation and ulceration. Plantar skin tissue thickness decrease in patients with type 2 diabetes mellitus with neuropathy compared to non-neuropathic patients with diabetes, adding to the increased risk for ulceration. [9]   Even once healed, the tissue surrounding former ulceration is at increased risk for rapid breakdown and re-ulceration. [10]

Blood flow to the lower extremity is also an area where diabetes can affect the foot and ankle.

Three main arteries and their branches supply the six angiosomes of the foot and ankle. The posterior tibial artery originates from the popliteal artery and supplies the plantar foot. The peroneal artery originates from the posterior tibial artery and supplies the anterolateral ankle and rearfoot. The anterior tibial artery originates from the popliteal artery and continues into the foot as the dorsalis pedis artery. It supplies the anterior ankle and dorsal foot. [11]  

Patients with diabetes have an increased risk of developing peripheral arterial disease (PAD). PAD is the atherosclerotic occlusive disease of the lower extremities. While over half of patients can be asymptomatic, some patients may experience such symptoms as intermittent claudication (aching in lower extremities with activity and relieved with rest) and rest pain, or in more severe cases tissue loss and gangrene.

Neurologically, the foot receives innervation from five main nerves and their branches: the tibial, superficial peroneal, deep peroneal, sural, and saphenous nerves. The tibial nerve originates from the sciatic nerve and divides into the medial and lateral plantar nerves, which further divide into the digital nerves. The tibial nerve provides motor innervation to the posterior lower leg muscles and sensory innervations to the plantar foot and heel. The superficial peroneal nerve (SPN) originates from the common peroneal nerve and branches into the medial and intermediate dorsal cutaneous nerves. The SPN innervates the peroneus longus and brevis muscles and also provides the sensory function to the anterior lower leg and dorsal foot and toes (except for the first webspace). The deep peroneal nerve originates from the common peroneal nerve. It has motor innervations to the anterior compartment muscles and sensory innervations to the first web space. The sural nerve forms from the tibial nerve and peroneal nerve, and it provides sensory innervation to the posterior lateral lower leg and posterior-lateral foot. The saphenous nerve originates from the femoral nerve and provides sensory innervation to the medial-distal leg, ankle, and foot. [12] [13]

A neurological manifestation of diabetes is diabetic neuropathy. [14]  Distal symmetrical polyneuropathy is the most common type of diabetic neuropathy. It can involve a combination of sensory or motor neuropathy due to small and/or large nerve fiber dysfunction. Large fiber (A alpha/beta fiber damage) neuropathy is painless paresthesia with reduced sensations in vibration, joint position, touch, pressure, and loss of ankle reflexes. Small fiber (myelinated A-delta and unmyelinated C fiber damage) neuropathy is painful, burning, with reduced pain and temperature sensations.

Diabetic peripheral neuropathy usually starts distally in the toes and progresses proximally. With progression, the patient may start to notice decreased sensation in their upper extremities in a stocking-glove distribution. Symptoms may worsen at night during sleep. Muscle weakness may also develop later in the disease. The exact pathogenesis of diabetic peripheral neuropathy is still the subject of research; however, a major suspect in this process may be chronic hyperglycemia with related metabolic changes leading to a combination of direct axonal injury and nerve ischemia. [15] [16]

A dreaded complication of uncontrolled diabetes and peripheral neuropathy is Charcot neuroarthropathy (CN).  This condition is likely the result of both neurovascular changes (i.e., arteriovenous shunting causing increased blood flow and increased bone resorption) and micro-trauma. [17]  These changes result in collapsed joints and severe pedal deformities. The most common joint to collapse in CN is the tarsometatarsal joint, which leads to a rocker bottom deformity.

Patients with Charcot foot have a 17% chance annually to develop ulceration. The lower extremity amputation risk for CN patients who have ulceration is 12 times higher compared to patients who have Charcot foot without ulceration. [18]  Early detection and treatment of CN improve outcomes; therefore, astute providers should suspect CN when a diabetic patient presents with a warm, erythematous, edematous foot with possible pedal structural changes.

• Indications

All patients with diabetes should receive education on proper diabetic foot care. Prevention of diabetic foot complications includes identifying the at-risk foot, daily exam and inspection, patient/family/healthcare provider education, appropriate shoegear, and proper and early treatment of pre-ulcerative lesions. Higher risk patients should obtain a referral to podiatry for management and monitoring. The International Working Group on Diabetic Foot (IWGDF) classification recommends diabetic foot screening by a medical professional [19] :

• Once a year for individuals without peripheral neuropathy
• Every six months for individuals with peripheral neuropathy
• Every 3 to 6 months for individuals with peripheral neuropathy, peripheral arterial disease and/or foot deformity
• Every 1 to 3 months for individuals with peripheral neuropathy and history of pedal ulceration or lower extremity amputation 
• Contraindications

There are no contraindications to proper diabetic foot care. 

A basic diabetic foot exam requires minimal specialty instruments and is performable by most primary care, podiatric, or other physicians.

The neurological evaluation requires a Semmes-Weinstein monofilament for neuropathy and protective-sensation testing. A 128Hz-tuning fork can test vibratory sensation, and cotton wool can test tactile sensation. [3]

Vascular testing may require a Doppler ultrasound to assess blood flow.

During diabetic foot care, the caregiver may encounter ulcerations. If ulceration is present and requires debridement or offloading, scalpels, tissue nippers, and offloading padding (e.g., felt pads, foam pads, cushions) should be readily available.

For advanced wound care settings, an array of products should be available: gauze, cleaning solutions (e.g., saline, hydrogen peroxide, acetic acid), topical antimicrobials (e.g., povidone-iodine, cadexomer iodine, silver, medical-grade honey, moisture-retentive dressings (e.g., films, foams, alginates, hydrogels, hydrocolloids), vacuum-assisted closure devices, and bioengineered dressings. [20]  

An interdisciplinary approach to managing diabetic foot and its possible complications can reduce amputations up to 85%. Endocrinology, diabetology, vascular surgery, podiatry, orthotics, prosthetics, wound care nursing, and educators are crucial to caring for the diabetic foot. Other specialties that may play roles in diabetic foot care depending on medical issues and infection include infectious disease, nephrology, cardiology, dermatology, and others. Goals should be to medically optimize comorbidities, prevent pedal issues, and treat pedal complications.

• Preparation

Patients with diabetes should remove both shoes and socks before the exam. Clean and dry feet thoroughly prior to foot exam or dressing change. If performing a dressing change on a diabetic foot ulcer, wash hands before and after the dressing change. Patients should prepare a clean and sanitary environment to decrease the chances of contamination and infection.

• Technique or Treatment

The clinical diabetic foot exam includes four major components: dermatological, vascular, neurological, musculoskeletal. 

The dermatological exam includes a thorough evaluation of the entire foot and ankle, including interdigital spaces and nails. Hyperkeratosis requires debriding. Pre-ulcerative and ulcerative lesions need detailed documentation of location, size, depth, the appearance of wound base, peri-wound skin, undermining, tracking, probing to the bone, exudate quality, and signs of infection (e.g., warmth, erythema, malodor, crepitus). A temperature of greater than 3 to 4 degrees compared to the contralateral foot may indicate an infection or acute Charcot neuroarthropathy. Also, a prior history of ulcerations, treatments, and preventative modalities requires documentation. A baseline foot radiograph is in order for patients with new ulcerations, and if osteomyelitis is concerned, the clinician should obtain serial radiographs for monitoring and exclusion. [21]

Clinical evaluation of vascularity and PAD starts with a thorough medical history (e.g., PAD risk factors, claudication, rest pain, history of non-healing wounds). Palpation of dorsalis pedis and posterior tibial arteries are the baseline for diabetic foot exams, but palpation of popliteal and femoral pulses can further assess the level of PAD. A decrease in pedal pulses may warrant evaluation with a Doppler ultrasound or further non-invasive testing for PAD. A Doppler ultrasound of pedal arteries can reveal triphasic flow (normal), biphasic flow (some arterial disease), monophasic flow (PAD with risk for limb ischemia), or absent (severe PAD and high risk for ischemia and limb loss). Non-invasive vascular tests include vascular labs (i.e., ankle-brachial index (ABI), segmental pressures, pulse volume recording, toe pressures, and transcutaneous partial pressure of oxygen [TcPO2]) and treadmill functional testing. The American Diabetes Association (ADA) recommends a screening ABI in patients with diabetes greater than 50 years old, and if normal, a repeat ABI should take place every five years. Screening ABI in patients with diabetes less 50 years old should be a consideration if they also have PAD risk factors (e.g., smoking, hypertension, hyperlipidemia, diabetes greater than ten years). If any indications of PAD are present during these exams, a referral to vascular surgery should follow. [22] [21]

The diabetic foot neurological exam consists of Achilles reflex testing, Semmes-Weinstein monofilament testing (SWMT), 128 Hz tuning fork testing, and pinprick testing. The Achilles reflex is performed on bilateral Achilles tendon with a reflex hammer. Reflexes are graded as 0+ (absent), 1+ (decreased), 2+ (brisk, normal), 3+ (increased), 4+ (increased with clonus). The 5.07/10 g SWMT is the most commonly used monofilament and examines pressure/light touch sensation. It should test for ten sites on each foot as follows: Distal first toe, distal third toe, distal fifth toe, plantar first metatarsal head, plantar third metatarsal head, plantar fifth metatarsal head, plantar medial and lateral arch, plantar heel, and dorsal first interspace. The 128-Hz non-graduated standard tuning fork tests vibratory sensation, and an abnormal result can reveal diabetic neuropathy if the patient can no longer distinguish vibration. The pinprick can be performed with a sharp pin device and evaluates whether the patient can distinguish sharp vs. dull sensations. [23] [24] [25]

Musculoskeletal evaluation should determine lower extremity muscle strength and foot or ankle deformities and limitations. The flexibility and rigidity of the joint range of motion should be determined to guide treatment options. As mentioned previously, patients with diabetes are at higher risk of developing pedal deformities such as digital contractures and ankle equinus, which increases the risk for ulceration. For example, a flexible ankle equinus due to gastrocnemius tightness may result in increased plantar foot pressures and tissue breakdown in the neuropathic patient.  Patients with pedal deformities should be referred to podiatry or other surgical practitioners for further management as they may benefit from surgical correction. For example, a digital flexor tenotomy may help in preventing distal toe ulcerations where tissue breakdown has developed. [26]  

Patient and family education and enforcement of proper diabetic foot care should be also be provided during the visit. [27]  

Patients should understand the importance of ambulating in protective shoegear, both indoors and outdoors. They should wear properly fitted shoes to prevent ulcerations. Additionally, patients with diabetes may require specialized shoegear and should undergo evaluation for such during the diabetic foot exam. The appropriate offloading and protective modality will depend on an individualized assessment of biomechanical changes, pressure points, and pathology. Shoe modifications, temporary shoegear, toe spacers, orthosis, and offloading felt pads or foam may all assist in protecting the diabetic foot. [28]  

• Complications

Poor diabetic foot care increases the risk of ulceration, infection, and limb loss. Armstrong D.G. and Harkless L.B. found that noncompliant patients, defined as missing greater than 50% of scheduled appointments in 1 year, are 54 times more likely to develop pedal ulcerations and 20 times more likely to have amputations compared to compliant patients. [29]  One study found that patients with diabetes fear major lower extremity amputations more than death, foot infection, or end-stage renal disease. [30]  Another study found that amputation had the greatest effect on the quality of life when compared to other diabetes complications (i.e., stroke, blindness, renal failure, heart failure, myocardial infarction). [31]  Therefore, high-risk limbs require close monitoring and care by specialists such as podiatrists.

• Clinical Significance

Proper diabetic foot care is a crucial aspect of diabetes treatment for limb preservation. One of the leading causes of hospitalization and amputation in patients with diabetes is foot ulcerations. The majority of diabetic foot complications result from ischemia, neuropathy, and/or infection. Patients with diabetes and neuropathy have a 7 to 10% chance of developing foot ulceration each year, and the probability increases to 25 to 30% for patients with more risk factors (e.g., peripheral arterial disease, pedal deformities, previous amputation or ulcerations). 85% of amputations on Patients with diabetes are secondary to complications from foot ulcerations. Patients with diabetes over 45 years old are eight times more likely to have an amputation, over 65 years old are 12 times more likely, and 65 to 74 years old are 23 times more likely. [3]

• Enhancing Healthcare Team Outcomes

Diabetic foot care requires interprofessional care. The severity of amputation, length of stay, and mortality rates improved in patients receiving care from a team when compared to those who did not. There may also be an improvement in regards to ulcer healing and quality of life. [32] [Level 1]

Proper diabetes management is an essential part of diabetic foot care. In addition to routine management with endocrinology/diabetology, studies show that a group-based self-management education system improves body weight, fasting blood glucose, waist circumference, diabetic knowledge, and triglyceride levels. These monitoring activities can fall between the clinicians, nursing, and pharmacists; in any event, the results and observations require charing and communication with the rest of the team. Interventions done by interprofessional teams with peer supporters improved HgA1c when compared to peer-led groups. [33] [Level 1] Diabetic and foot care nurses are often responsible for foot assessment. They should also educate patients regarding proper foot care. However, all members of the interprofessional team bear responsibility for this training, from nursing to pharmacists, and of course, all clinicians - this interprofessional collaboration can improve patient self-care as well as outcomes, preventing many adverse sequelae as outlined above. [Level 5]

• Nursing, Allied Health, and Interprofessional Team Interventions

Intensive patient education (e.g., lifestyle management, podiatric care, proper examinations, callus management) for diabetic foot care by nursing helps prevent diabetic foot ulcerations and decrease the amputation rate for high-risk diabetic feet. Also, intensive education helps to lower plasma glucose, blood pressure, and high-density lipoprotein cholesterol levels. [34]

• Nursing, Allied Health, and Interprofessional Team Monitoring

Care for the diabetic foot is an interprofessional responsibility. Holstein et al. found a 75% decrease in major limb amputations in patients with diabetes when establishing an interdisciplinary/interprofessional foot clinic with increased revascularization rates. [35]  Primary care physicians and nursing can identify the diabetic foot and provide extensive education on proper care and monitoring. A patient with increased risk factors and pedal deformities should be followed regularly by podiatry. If ulcerations develop, more frequent monitoring may be required and may need a referral to other specialists such as vascular surgery, infectious disease, plastic surgery, and prosthetics. 

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Diabetic foot model showing full-thickness ulceration on far left side of picture, and pre-ulcerative lesion on far right. Contributed by Aaron R. Chambers, DPM, FACFAS

T2-weighted MRI image of a patient's right foot. Patient had history of uncontrolled diabetes, peripheral neuropathy and a long-standing ulceration under the 5th metatarsal head resulting in osteomyelitis of the 5th metatarsal head and shaft. Patient (more...)

Xray of a patient's right foot after undergoing partial ray resection of the 5th metatarsal for acute osteomyelitis. Patient had history of uncontrolled diabetes, peripheral neuropathy and a long-standing ulceration under the 5th metatarsal head resulting (more...)

Disclosure: Kayla Song declares no relevant financial relationships with ineligible companies.

Disclosure: Aaron Chambers declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Song K, Chambers AR. Diabetic Foot Care. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.

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Tips for Healthy Feet

What to know.

People with diabetes can help prevent serious foot problems by following these tips for healthy feet. Infographic available in sizing for Facebook and X (formerly Twitter).

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Most people with diabetes can prevent serious foot problems..

Check your feet every day for cuts, redness, swelling, sores, blisters, corns, or calluses.

Wash your feet every day in warm (not hot) water and dry them well.

Never go barefoot , even inside.

Wear shoes that fit well and always wear socks.

Trim your toenails straight across and smooth out sharp edges with a nail file.

Don't try to remove corns or calluses yourself .

Get your feet checked at every health care visit and visit your foot doctor at least once a year.

Diabetes is a chronic disease that affects how your body turns food into energy. About 1 in 10 Americans has diabetes.

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