How to Prevent Diabetic Foot Ulcers

Why are people with diabetes at higher risk for foot ulcers?

Two overlapping complications drive diabetic foot ulcer risk:

Peripheral neuropathy. High blood glucose damages the small nerve fibers in the feet over time, reducing sensation of pain, heat, and pressure. A person with significant neuropathy may not feel a blister, a foreign body in the shoe, or a wound forming — the body's normal early warning system is quieted.

Peripheral vascular disease. Diabetes accelerates atherosclerosis in the vessels of the legs and feet, reducing blood flow. Tissue with poor circulation heals slowly and is more vulnerable to infection once a wound opens.

When neuropathy and reduced circulation combine, even a minor pressure point or skin break can evolve into a deep, slow-healing ulcer. The International Working Group on the Diabetic Foot (IWGDF) guidelines identify offloading (reducing pressure on the ulcer) and blood glucose optimization as the cornerstones of management once an ulcer develops — which underscores how valuable prevention is before that point is reached. 1Ref 1Chen P, Vilorio NC, Dhatariya K, Jeffcoate W, Lobmann R, McIntosh C, Piaggesi A, Steinberg J, Vas P, Viswanathan V, Wu S, Game F (2024).Guidelines on Interventions to Enhance Healing of Foot Ulcers in People With Diabetes (IWGDF 2023 Update).Identifies offloading and blood glucose optimization as cornerstones of diabetic foot ulcer management; underscores importance of prevention and daily inspection2Ref 2Bus SA, Armstrong DG, Crews RT, Gooday C, Jarl G, Kirketerp-Moller K, Viswanathan V, Lazzarini PA (2024).Guidelines on Offloading Foot Ulcers in Persons With Diabetes (IWGDF 2023 Update).Recommends therapeutic footwear to reduce pressure points; supports the importance of plantar stress reduction in people with diabetic neuropathy

The CDC notes that the vast majority of diabetes-related lower limb amputations are preceded by a foot ulcer, making prevention one of the most consequential things a person with diabetes can do for their long-term health. 3Ref 3Centers for Disease Control and Prevention (2023).Preventing Diabetes-Related Amputations.The vast majority of diabetes-related lower limb amputations are preceded by a foot ulcer, making prevention a high-impact priority

How should you inspect your feet every day?

Daily inspection is the single most recommended preventive action in diabetic foot care guidelines. 1Ref 1Chen P, Vilorio NC, Dhatariya K, Jeffcoate W, Lobmann R, McIntosh C, Piaggesi A, Steinberg J, Vas P, Viswanathan V, Wu S, Game F (2024).Guidelines on Interventions to Enhance Healing of Foot Ulcers in People With Diabetes (IWGDF 2023 Update).Identifies offloading and blood glucose optimization as cornerstones of diabetic foot ulcer management; underscores importance of prevention and daily inspection2Ref 2Bus SA, Armstrong DG, Crews RT, Gooday C, Jarl G, Kirketerp-Moller K, Viswanathan V, Lazzarini PA (2024).Guidelines on Offloading Foot Ulcers in Persons With Diabetes (IWGDF 2023 Update).Recommends therapeutic footwear to reduce pressure points; supports the importance of plantar stress reduction in people with diabetic neuropathy

What to look for: - Redness, blistering, or broken skin anywhere on the foot - Cracks or fissures, especially around the heel - Swelling on one foot but not the other (asymmetry can signal infection or a Charcot fracture) - Darkened skin or areas of color change - Calluses that are thickening, especially over bony prominences - Any nail changes — discoloration, thickening, or ingrown edges

How to do it: - Sit in good light after removing shoes and socks. - Use a mirror or a smartphone camera to see the bottom of the foot if bending is difficult. - Check between every toe — this is where moisture and breakdown are easily missed.

If you find anything new or abnormal, do not wait to see if it resolves on its own. Contact a clinician the same day.

What footwear protects diabetic feet?

Footwear is one of the most modifiable risk factors for diabetic foot ulcers. IWGDF guidelines specifically recommend therapeutic footwear to reduce pressure points and plantar stress in people at elevated risk. 2Ref 2Bus SA, Armstrong DG, Crews RT, Gooday C, Jarl G, Kirketerp-Moller K, Viswanathan V, Lazzarini PA (2024).Guidelines on Offloading Foot Ulcers in Persons With Diabetes (IWGDF 2023 Update).Recommends therapeutic footwear to reduce pressure points; supports the importance of plantar stress reduction in people with diabetic neuropathy

Practical principles:

• Always wear shoes outdoors — and indoors too if you have significant neuropathy or reduced sensation. Many wounds happen when someone steps on a small object they did not feel.
• Do not wear shoes that are too tight. Because neuropathy blunts the discomfort signal that would otherwise tell you a shoe is rubbing, you may not feel a pressure sore forming until it is well established.
• Choose rounded toes and cushioned soles. A roomy toe box prevents pressure on toes; cushioned soles reduce plantar stress with each step.
• Inspect shoes before putting them on every time. Run a hand inside to feel for foreign objects, torn lining, or seams that have shifted.
• Wear seamless or low-seam socks. Thick socks with prominent seams can create pressure points invisible to neuropathic feet.
• Consider diabetic shoes or custom orthotics if you have had previous ulcers, structural deformities (hammertoes, Charcot foot), or very high plantar pressure readings. Your clinician or a podiatrist can refer you to therapeutic footwear resources.

The NIDDK patient guidance emphasizes never going barefoot — indoors or outdoors — as a simple but high-impact habit for people with diabetes. 4Ref 4National Institute of Diabetes and Digestive and Kidney Diseases (2017).Diabetes & Foot Problems.Recommends never going barefoot as a high-impact preventive habit for people with diabetes

How should you care for diabetic skin and nails?

Skin care: - Wash feet daily with mild soap and lukewarm water (not hot — neuropathy affects temperature sensation too). - Dry thoroughly, including between toes. Excess moisture between toes promotes fungal infection and skin breakdown. - Apply a fragrance-free moisturizer to the tops and soles of the feet after drying, but avoid putting it between the toes. - Do not use pumice stones or callus-removal products aggressively. Callus thinning can be done safely, but over-aggressive removal can breach the skin.

Nail care: - Cut nails straight across — not curved — and file any sharp edges smoothly. - Avoid cutting nails too short; this increases the risk of ingrown nails. - If you cannot reach your feet safely, have limited vision, or have thickened nails, a podiatrist should manage nail care. Podiatrists specialize in lower extremity care and are the right specialist for complex or higher-risk nail and foot issues in people with diabetes.

How does blood sugar control affect foot ulcer risk?

Blood glucose management is the upstream intervention that shapes everything downstream. Prolonged hyperglycemia accelerates neuropathy and vascular damage — both of the conditions that drive foot ulcer development in the first place. The ADA Standards of Care set individualized glycemic targets, with the recognition that better long-term glucose control reduces the cumulative risk of microvascular and neuropathic complications. 5Ref 5American Diabetes Association Professional Practice Committee (2024).Standards of Care in Diabetes—2024.Sets individualized glycemic targets and recommends annual foot examination including sensory testing and vascular assessment for all people with diabetes

For people who already have neuropathy, tighter glucose control can slow its progression, though it cannot fully reverse established nerve damage. Foot care habits and glucose management work together, not in isolation.

How often should a person with diabetes have their feet examined by a clinician?

A complete foot examination — checking sensation, pulses, skin integrity, and footwear — is recommended at least annually for all people with diabetes, and more frequently for those with neuropathy, previous ulcers, or vascular disease. 1Ref 1Chen P, Vilorio NC, Dhatariya K, Jeffcoate W, Lobmann R, McIntosh C, Piaggesi A, Steinberg J, Vas P, Viswanathan V, Wu S, Game F (2024).Guidelines on Interventions to Enhance Healing of Foot Ulcers in People With Diabetes (IWGDF 2023 Update).Identifies offloading and blood glucose optimization as cornerstones of diabetic foot ulcer management; underscores importance of prevention and daily inspection5Ref 5American Diabetes Association Professional Practice Committee (2024).Standards of Care in Diabetes—2024.Sets individualized glycemic targets and recommends annual foot examination including sensory testing and vascular assessment for all people with diabetes

Your Gale primary care clinician can perform this examination, counsel on footwear and skin care, and refer to a podiatrist for complex issues such as nail care in high-risk patients, callus management, or custom orthotics.