September 11, 2026
Diabetes can affect the feet in several ways, and what may initially appear to be a small or insignificant problem can develop into a serious complication if it is not identified and managed early.
From a podiatry perspective, diabetic foot care is not simply about treating ulcers. It is about prevention, early detection and reducing the factors that place a person at risk of tissue breakdown, infection and, ultimately, amputation.
Diabetes can contribute to three major problems affecting the lower limb: neuropathy, peripheral arterial disease and impaired wound healing.
Diabetic peripheral neuropathy can reduce or completely alter protective sensation. A patient may develop a blister, cut, burn or pressure injury without feeling it. This is particularly concerning when repetitive pressure continues from walking or poorly fitting footwear.
Peripheral arterial disease can reduce blood flow to the foot, compromising the delivery of oxygen and nutrients required for healthy tissue and wound healing.
When neuropathy, poor circulation and mechanical stress occur together, the risk of ulceration increases significantly.
A comprehensive diabetic foot assessment should look beyond the skin.
The podiatrist should assess:
NICE recommends that adults with diabetes have their feet assessed when diabetes is diagnosed and at least annually thereafter, with reassessment whenever a foot problem develops or there is a significant change in clinical status. The assessment should include examination for neuropathy, ischaemia, ulceration, callus, infection, deformity, gangrene and Charcot arthropathy.
Not every person with diabetes has the same level of risk.
Someone with diabetes who has intact sensation, adequate circulation and no significant deformity may require routine surveillance. Conversely, a patient with neuropathy, peripheral arterial disease, previous ulceration, amputation or renal replacement therapy may require much closer monitoring.
NICE categorises patients according to their risk, with moderate- and high-risk patients requiring referral to an appropriate foot protection service.
This is where podiatry becomes particularly important. Identifying risk before an ulcer develops allows intervention to take place when the foot is still intact.
One of the most important lessons in diabetic foot care is that callus should never automatically be considered cosmetic.
Excess callus can indicate repetitive mechanical stress and increased pressure beneath the foot. In a patient with reduced sensation, this pressure may continue without the patient being aware of it.
A podiatrist can safely manage excessive callus while also investigating why it has developed in the first place.
Is there a prominent metatarsal head? A deformity? Limited joint mobility? An inappropriate shoe? An abnormal gait?
Treating the callus without addressing the underlying mechanical cause may simply allow the problem to return.
The IWGDF recommends appropriate treatment of pre-ulcerative lesions and excess callus in people at risk of diabetic foot ulceration.
Footwear is one of the most important preventative tools available to podiatry.
Shoes should accommodate the shape of the foot, provide sufficient space for the toes and minimise excessive pressure and friction.
For patients at moderate to high risk, therapeutic footwear may be required. For people with previous plantar ulceration, footwear designed to demonstrably reduce plantar pressure can help reduce the risk of recurrence.
This is why footwear assessment should form part of a diabetic foot consultation rather than being treated as an afterthought.
Good diabetic foot care also depends on what happens between appointments.
Patients at risk should be encouraged to:
IWGDF guidance specifically recommends educating people at risk not to walk barefoot or in socks without shoes, and recommends appropriate daily foot hygiene and skin care.
The goal is not simply to tell patients what to do. Effective podiatry involves explaining why these behaviours matter and helping patients incorporate them into their everyday routine.
One of the most important clinical warning signs is a new, hot, swollen or discoloured foot, particularly in a person with neuropathy.
A patient may not experience significant pain despite substantial underlying pathology.
Acute Charcot neuro-osteoarthropathy should therefore be considered when there is an unexplained hot, swollen foot, particularly when there has been a change in colour. NICE identifies this as an active diabetic foot problem requiring urgent specialist assessment.
Early recognition is critical because continued weight-bearing on an unstable Charcot foot can contribute to progressive deformity and further complications.
Once an ulcer is present, the focus shifts from prevention to rapid assessment and multidisciplinary management.
The ulcer should be assessed in relation to its depth, infection status, vascular supply, location and mechanical loading.
Offloading is particularly important because mechanical stress can prevent an ulcer from healing. The IWGDF identifies offloading mechanical tissue stress as one of the most important interventions for healing a diabetes-related foot ulcer.
Depending on the presentation, management may involve podiatry, diabetology, vascular surgery, wound care, orthopaedics, microbiology and other members of the multidisciplinary team.
NICE recommends that specialist diabetic foot services have access to expertise across these disciplines, reflecting the complexity of diabetic foot disease.
Perhaps the biggest misconception surrounding diabetic foot care is that patients should see a podiatrist only when something is wrong.
In reality, the greatest opportunity for podiatry is often before the ulcer appears.
Identifying neuropathy, vascular compromise, deformity, excessive pressure, callus or inappropriate footwear gives the clinician an opportunity to intervene early.
The 2023 IWGDF prevention guideline recommends regular risk assessment, appropriate foot self-care education, treatment of pre-ulcerative lesions and integrated foot care for people at moderate to high risk.
A podiatrist can play a central role in protecting the diabetic foot through:
Assessment — identifying neurological, vascular, dermatological and biomechanical risk factors.
Prevention — managing callus, nails, skin problems and pre-ulcerative lesions.
Biomechanics — identifying abnormal loading and pressure contributing to tissue damage.
Footwear — recommending appropriate footwear, insoles and offloading solutions.
Education — helping patients recognise early warning signs and understand daily foot care.
Early intervention — recognising ulcers, infection, ischaemia and possible Charcot neuroarthropathy and arranging appropriate escalation.
Multidisciplinary care — working alongside medical, vascular, wound-care and surgical colleagues when required.
The diabetic foot should never be assessed in isolation.
A small callus may represent abnormal pressure. A painless blister may be the beginning of an ulcer. A swollen foot may represent Charcot neuroarthropathy. A non-healing wound may indicate significant vascular disease.
For podiatry, the priority is therefore not simply to treat what is visible.
It is to understand why it happened, identify the patient’s risk, remove the contributing factors and prevent recurrence.
Early podiatric intervention can make a significant difference to the long-term health of the diabetic foot. As the IWGDF emphasises, prevention and integrated foot care are central to reducing the burden of diabetes-related foot disease.
Healthy diabetic feet are not achieved by waiting for problems to appear they are protected through assessment, education, prevention and early intervention.
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