I am going to tell you something that I wish I could communicate to every person with diabetes in my practice: the foot you ignore today may be the foot that kills you in ten years.
This is not hyperbole. Diabetic foot disease — the combination of neuropathy (nerve damage) and poor circulation that makes foot injuries in people with diabetes so dangerous — is the leading cause of non-traumatic lower limb amputation in the UK. Approximately 135 people with diabetes have a lower limb amputation in the UK every week. The five-year mortality rate after a major amputation from diabetic foot disease is around 50% — worse than many cancers.
And the extraordinary thing is that the majority of these amputations are preventable.
The two mechanisms that make diabetic feet vulnerable
Diabetic peripheral neuropathy: High blood sugar over time damages the small nerve fibres in the feet and legs. The earliest symptom is often tingling or burning sensation. As it progresses, sensation is lost — people cannot feel pain from cuts, blisters, pressure sores, or burns.
This loss of protective sensation is extraordinarily dangerous. Pain is a warning system. Without it, a small injury — a blister from a tight shoe, a cut from a nail, a burn from a hot water bottle — goes unnoticed and untreated. In a person without diabetes, these minor injuries heal within days. In someone with compromised circulation and immune function from diabetes, they can progress to serious infection within days.
Peripheral arterial disease (PAD): Diabetes accelerates atherosclerosis in the blood vessels of the legs and feet. Reduced blood flow means reduced oxygen delivery to tissues, reduced immune cell delivery to fight infection, and severely impaired wound healing.
The combination of neuropathy (can't feel the injury) and PAD (can't heal the injury) is what makes diabetic foot disease so devastating.
What to check every day — the daily foot inspection
This is the single most important practice for people with diabetes. Every day, remove your shoes and socks and look at your feet — top, bottom, between all toes. You are looking for:
- Any cuts, breaks, or blisters — no matter how small
- Redness, swelling, or warmth in any area
- Any areas of colour change — pale, red, or dark discolouration
- Any new calluses or corns
- Any changes in the shape of your foot
If you cannot see the bottom of your feet clearly — use a mirror, a smartphone camera, or ask a family member to check for you.
Case study: Emmanuel's preventable amputation
Emmanuel, 61, had type 2 diabetes for 14 years, managed with tablets. He came to see me not for diabetes but for what he described as "a small sore on my foot that's not getting better."
The "small sore" was a 2cm ulcer on the sole of his right foot, surrounded by a halo of redness extending up his ankle. There was necrotic tissue at the base. He had no pain — he had not noticed it until his wife saw it during a bath two days earlier.
He had no recollection of how it started. The most likely cause: a small blister from new shoes that he had not felt, which had broken, become infected, and progressed over approximately two weeks while he walked on it every day, unaware.
He was admitted urgently. He had significant peripheral arterial disease. Despite IV antibiotics and surgical debridement, the infection was not controlled. He underwent partial foot amputation.
He had never been told to check his feet daily. He had not had a formal foot examination in his diabetes review in over three years.
This story is not unusual. It is preventable.
The annual foot check — what should happen
Every person with diabetes should have a formal foot examination at least annually as part of their diabetes review. This includes:
- Inspection for deformity, callus, ulceration, and infection
- Assessment of sensation using a 10g monofilament
- Assessment of pulses (dorsalis pedis and posterior tibial)
- Assessment of skin condition and nail health
- Risk stratification — low, moderate, or high risk
If your diabetes review does not include a foot examination, ask for one. If it has not been done in the past year, request it now.
High-risk feet (previous ulceration, loss of sensation, absent pulses, or foot deformity) should be seen by a podiatrist every 3 months.
Practical foot care — what to do daily
Wash feet daily in lukewarm water (test with elbow — people with neuropathy cannot reliably test water temperature with their feet and risk burns). Dry thoroughly, especially between toes — moisture between toes promotes fungal infection and skin breakdown.
Moisturise the skin of the feet (but not between the toes) daily with a simple unperfumed cream. Dry, cracked skin is a portal for infection.
Cut nails straight across — not curved — to prevent ingrown toenails. If you cannot see or reach your feet safely, use a podiatrist.
Never walk barefoot — not at home, not on the beach, not anywhere. Neuropathic feet cannot feel what they step on.
Choose footwear carefully — well-fitting, soft leather or fabric upper, no seams inside, wide toe box, low heel. Avoid shoes that rub or create pressure points. Break new shoes in gradually.
Never use corn plasters or sharp instruments on corns and calluses — see a podiatrist. Chemical corn treatments can cause chemical burns in insensate feet.
Avoid hot water bottles in contact with feet — a significant cause of serious burns in people with diabetic neuropathy.
Blood sugar control — the most important preventive measure
Good blood sugar control significantly reduces the risk and progression of neuropathy and slows the development of peripheral arterial disease. The DCCT and UKPDS trials both demonstrated that tighter glycaemic control reduces the risk of microvascular complications — including neuropathy — by 60–70%.
SGLT2 inhibitors (empagliflozin, dapagliflozin) reduce cardiovascular events and kidney disease progression in diabetes — and their cardiovascular benefits likely extend to peripheral arterial disease. If you have type 2 diabetes with established cardiovascular disease or high risk, ask your GP whether an SGLT2 inhibitor is appropriate for you.
Free podiatry — know your entitlement
People with diabetes are entitled to free NHS podiatry. This is not universally known or consistently offered. If you have diabetes and foot problems — calluses, corns, nail problems, any skin breaks — you can ask your GP to refer you to NHS podiatry. You do not need to pay for private podiatry for diabetes-related foot care.
Sources: Diabetes UK — Putting Feet First campaign 2024; NICE Clinical Guideline NG19 — Diabetic Foot Problems: Prevention and Management (2015, updated 2023); NHS Digital — National Diabetes Foot Care Audit 2023; DCCT Research Group, NEJM 1993; Prompers L et al, Diabetologia 2007 (Eurodiale study).
