Diabetic foot disease is the leading cause of non-traumatic lower limb amputation in the UK. Every week in the UK, approximately 135 people with diabetes have a lower limb amputation. The five-year mortality rate after a major lower limb amputation from diabetic foot disease is approximately 50% - comparable to many aggressive cancers.
And the majority of these amputations are preventable.
That is not a clinical cliche. It reflects the documented evidence from centres that invest in foot surveillance, early intervention, and multidisciplinary foot care: they have dramatically lower amputation rates than centres that do not. The difference is not in the severity of diabetes - it is in whether the system catches foot problems when they are still small.
I want to tell you something clearly: the foot you ignore today may be the foot that costs everything in ten years. The relationship between daily foot care and the prevention of amputation is not metaphorical. It is direct and well-documented.
Why diabetes is so dangerous for feet
The danger comes from the combination of two complications that frequently coexist in people with longstanding or poorly controlled diabetes.
Diabetic peripheral neuropathy: High blood glucose over time damages the small nerve fibres in the feet and lower legs. This happens gradually and painlessly. The first symptom is often tingling or burning sensations - but as neuropathy progresses, these sensations are replaced by numbness. The feet lose the ability to feel pain, temperature, and pressure changes.
This loss of protective sensation is extraordinarily dangerous. Pain exists to protect us. Without pain, a cut from a sharp stone, a blister from a tight shoe, a burn from an overheated hot water bottle, or a pressure sore from sitting in one position for too long - all go unnoticed. In someone without diabetes, these small injuries heal within days. In someone with diabetes and compromised circulation, they can progress to serious infection.
The tragedy is that the person cannot feel the injury happening. They may walk on a significant wound for days before anyone notices.
Peripheral arterial disease (PAD): Diabetes accelerates atherosclerosis in the blood vessels of the legs and feet. Reduced blood flow in the smaller vessels of the foot means two things: impaired delivery of immune cells to fight infection, and severely impaired wound healing. Without adequate blood flow, wounds cannot heal.
The combination - cannot feel the injury, cannot heal the injury - is what makes diabetic foot disease so potentially catastrophic.
What to check and how to check it - every day
Foot self-examination should be performed every day, ideally when removing shoes and socks at the end of the day. Use good lighting.
What to look for:
Any cut, break, blister, or wound however small. Between the toes is a particularly easy place to miss - check carefully.
Any redness, especially spreading redness around an area that was previously normal.
Any swelling in one foot or part of the foot - asymmetric swelling is particularly important.
Any colour changes - pallor (white or blue colouring) may indicate arterial compromise. Dark discolouration around a wound may indicate necrosis.
Any areas of increased warmth compared to the rest of the foot or to the other foot.
Any new calluses or corns - these indicate abnormal pressure that can lead to ulceration underneath.
Any change in foot shape - unusual prominences or deformities that develop over time.
If you cannot see the bottom of your feet clearly, use a long-handled mirror, ask a family member to check, or use your smartphone camera.
What to do and not do
Do: Wash feet daily in lukewarm water. Test temperature with your elbow - neuropathic feet may not reliably detect temperature, and scalds are a significant cause of injury.
Dry thoroughly, particularly between toes. Moisture between toes creates ideal conditions for fungal infection.
Moisturise daily with a good foot cream or lotion - the tops and soles of the feet, but not between the toes.
Cut or file toenails regularly, straight across. Never cut down the sides - this leads to ingrown toenails.
Always wear shoes or slippers. Never walk barefoot - not at home, not on the beach, not in the garden. The ground is full of hazards that a neuropathic foot cannot detect.
Choose footwear that is well-fitting, wide enough to accommodate the toes, soft inside with no internal seams, and supportive. Break new shoes in gradually - alternate with old shoes and build up wearing time slowly.
Check inside shoes before putting them on. A small stone or folded sock material inside a shoe can cause significant injury to a neuropathic foot.
Do not: Use corn plasters or over-the-counter corn removal products on diabetic feet. The active chemical in corn plasters (salicylic acid) can damage surrounding tissue.
Use sharp instruments on corns, calluses, or nails. See a podiatrist.
Apply hot water bottles directly to feet. Burns from hot water bottles in neuropathic feet are a significant and entirely preventable cause of serious foot injury.
Soak feet for prolonged periods - prolonged soaking softens skin and increases vulnerability to breakdown.
Ignore any wound, however small. A small wound in a diabetic foot is not the same as a small wound in anyone else.
Case study: Emmanuel's preventable amputation
Emmanuel, 61, came to see me not to discuss his diabetes but because of what he described as a small sore on my foot that is not getting better.
The wound on examination was a 2cm ulcer on the plantar surface (sole) of his right foot, around the first metatarsal head. There was surrounding erythema (redness) extending up the medial side of the foot toward the ankle. The wound base had necrotic tissue. He had no sensation in the area.
He was not sure when it had started. He estimated perhaps two or three weeks. He had been wearing his usual work shoes throughout.
He had been walking on a deep, infected diabetic foot ulcer for what appeared to be 2-3 weeks without realising it was there. The most likely cause: a small blister or cut, possibly from new shoes, that had broken and become infected while he was unaware.
He was admitted directly from my consultation room.
Despite IV antibiotics, surgical debridement, and vascular surgery review, the infection was not controlled. He underwent partial right foot amputation.
He had never been told to check his feet daily. His last documented formal foot examination in a diabetes review was over 3 years earlier.
This story is not unusual. It is preventable.
Your NHS entitlements regarding foot care
People with diabetes are entitled to annual foot examination within their NHS diabetes review. This should include:
Assessment of neuropathy (monofilament testing and/or vibration sense), assessment of peripheral vascular disease (pedal pulse check and ankle-brachial pressure index if indicated), skin and nail examination, foot risk stratification, and education about foot care.
You are also entitled to NHS podiatry referral. If you have diabetes and have not had a formal foot assessment in the past year, request one at your next diabetes review. If you have neuropathy, any foot abnormality, or previous foot problems, you should be under regular NHS podiatry care.
Sources: Diabetes UK - Putting Feet First 2024; NICE Clinical Guideline NG19 - Diabetic Foot Problems: Prevention and Management 2023; NHS Digital - National Diabetes Foot Care Audit 2023; Prompers L et al, Diabetologia 2007 (diabetic foot outcomes in Europe); Driver VR et al, Journal of the American Podiatric Medical Association 2010 (diabetic foot disease burden).
