The International Diabetes Federation estimates that more than half a billion adults live with diabetes, and numbers are rising fastest in Africa and Asia. Foot ulcers are among the most serious complications: they are a leading cause of non-traumatic lower limb amputation, and many people die within a few years of an amputation. Most of this is preventable through regular foot checks, education and fast action when problems appear. Nurses are central to all three.
Why diabetes damages feet
- Neuropathy (nerve damage): loss of feeling means injuries go unnoticed. Changes in foot shape increase pressure points.
- Peripheral arterial disease (poor circulation): wounds heal slowly and infections spread.
- High glucose impairs immunity and healing.
- Ill-fitting shoes, walking barefoot, cracks, corns and fungal infections are common triggers.
The foot examination
Every person with diabetes should have their feet examined at least once a year, and more often if at risk. Remove shoes and socks and check both feet:
- Skin: colour, dryness, cracks (especially heels), calluses, blisters, ulcers, nail problems, fungal infection between toes.
- Shape: bunions, claw or hammer toes, collapsed arch (possible Charcot foot).
- Circulation: palpate the dorsalis pedis and posterior tibial pulses; check temperature and capillary refill.
- Sensation: use a 10 g monofilament at several sites on each foot, as per your protocol. If the patient can’t feel it, they have loss of protective sensation. A 128 Hz tuning fork or the “Ipswich touch test” (lightly touching the tips of toes) are alternatives where monofilaments aren’t available.
- Footwear: look inside shoes for foreign objects and worn areas.
Classifying risk
| Risk | Typical features | Typical review |
|---|---|---|
| Low | No risk factors other than callus | Annually |
| Moderate | One risk factor: neuropathy, poor circulation or foot deformity | Every 3–6 months |
| High | Previous ulcer or amputation, kidney dialysis, or more than one risk factor | Every 1–2 months |
| Active foot problem | Ulcer, spreading infection, critical ischaemia, gangrene, suspected Charcot foot | Urgent referral to the multidisciplinary foot team (within 1 working day in NICE guidance) |
Teaching daily foot care
- Check your feet every day, including soles and between toes. Use a mirror or ask a family member.
- Wash daily in lukewarm water (test with your elbow, not your foot), and dry carefully, especially between toes.
- Moisturise dry skin, but not between the toes.
- Never walk barefoot, indoors or outdoors, including at the mosque, church or on hot sand. Use clean socks and well-fitting shoes.
- Check inside shoes before putting them on.
- Cut nails straight across; don’t cut corns yourself or use corn plasters or chemical treatments.
- Avoid hot water bottles, heaters and soaking feet.
- Control blood glucose, BP and cholesterol, and stop smoking.
- Seek help the same day for any cut, blister, colour change, swelling or pain.
A foot emergency
A diabetic foot with an ulcer and signs of infection (redness spreading, swelling, pus, warmth, smell, fever, or a rapidly worsening wound), or a cold, pale or black foot, is an emergency. Infection can spread rapidly, and patients with neuropathy may feel little pain. Arrange urgent assessment, antibiotics as prescribed, offloading (taking weight off the foot), and surgical review where needed. Delays cost limbs.
Wound care for diabetic foot ulcers
- Offloading is the most important treatment: total contact casts, removable walkers or special footwear.
- Debridement by trained staff; appropriate dressings (see our wound dressings guide).
- Assess circulation; refer for vascular review if pulses are absent.
- Treat infection; X-ray or other imaging if bone infection (osteomyelitis) is suspected.
- Optimise glucose control and nutrition.
Related: Hypoglycaemia · Diabetic ketoacidosis · Pressure ulcers
Based on International Working Group on the Diabetic Foot (IWGDF) guidelines, NICE NG19 and International Diabetes Federation data. Educational content: follow your local diabetic foot pathway.