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Diabetes and Foot Health

Published: 9/12/22
By Hope Warshaw

Woman stretching and holding her feet with two handsHaving diabetes puts you at risk for problems with your feet. There are steps you can take to keep your feet healthy as recommended in the latest ADA Standards of Care.​ 

If you have ever had a foot problem that wreaks havoc with your daily comings and goings, you recognize how important your feet are to living your life.

This article explores why people with diabetes can develop foot problems and how to keep your feet healthy, with suggestions based on guidance from the American Diabetes Association’s Standards of Care and information from the diabetes division of National Institutes of Health.  

Basics of diabetes-related foot problems

Most often, diabetes-related foot problems occur due to a combination of factors.

A first problem could be as simple as an ingrown toenail or a barefoot walk on a beach or on hot pavement. You may not feel the pain from a foot injury due to decreased sensation from peripheral neuropathy.  The injury can quickly get worse before you notice and seek medical care.  

Reduced circulation and blood flow in the lower legs and feet from neuropathy can increase the risk that the injury gets infected. Treatment may require antibiotics or the need to refrain from walking for a period of time. Healing an infection can be arduous and time-consuming. If the infection does not heal, amputation may be necessary. 

You can prevent these problems by keeping your glucose levels in range, practicing regular foot self-care, and getting an annual assessment and evaluation by your healthcare provider. In addition, examine your feet carefully (especially if you have neuropathy) and seek medical care immediately for any problem you detect.  

Risk Factors for Foot Problems

People with diabetes with one or more of the following conditions are at higher risk for developing foot problems: 

  • Consistently high glucose levels

  • Existing peripheral neuropathy with LOPS (Loss of Protective Sensation)

  • History of foot ulcers or amputation

  • Cigarette smoking

  • Foot deformity (see definitions below) 

  • Calluses or corns 

  • Peripheral artery disease (PAD) 

  • Visual impairment due to diabetes

  • Chronic kidney disease (especially people on dialysis)

Common Foot Problems

This list includes common foot deformities and problems in people with diabetes.  

  • Calluses: Build up of layers of hard skin typically on the bottom of a foot. 

  • Charcot’s Foot: Nerve damage to joints and soft tissue in a foot that can cause the foot to develop an odd shape, known as a rocker bottom. 

  • Corns: Build up of layers of hard skin on or near a bone in the toes or between toes. 

  • Dry skin: This can crack and allow germs to get in. Germs can cause infection. Keep skin moist to prevent dry skin.  

  • Fungal infection in toenails: Toenails with a fungal infection may change in color, get thick and thin. They are hard to heal. Seek medical help rather than trying over the counter aids. 

  • Hammertoe(s): A hammertoe tends to curl under the foot because the tendon from a weakened muscle becomes shorter. A hammertoe can often be treated without surgery, but some people need surgery to straighten the toe. 

  • Foot ulcer: These can develop from a simple scrape, sore or crack in the skin and if not treated quickly can become infected.  

  • Peripheral artery disease (PAD): Peripheral arteries carry blood from the heart to the legs and arms. PAD occurs when buildup of plaque on the walls of blood vessels narrows the arteries, reducing blood flow in the feet and legs. PAD is most often diagnosed when there is pain with walking, or numbness or tingling in the legs and feet. A  healthcare provider should check pedal pulses (on the top of the foot or behind the ankle bone) to assess circulation. Additional tests and treatment to increase circulation may be needed. 

How To Prevent or Delay Diabetes-Related Foot Problems

As is true for the prevention or delay of most diabetes-related problems, there are actions to take daily, like doing daily foot care and keeping glucose, blood pressure and lipids at target levels. There are also actions to take annually or more frequently, if need be, to detect a foot problem.  

Daily actions 

Get and keep glucose in a desired target range. Good glucose management over time can help reduce the risk of foot problems. Work with a  diabetes healthcare provider to determine glucose management targets that are best. 

Do not smoke, or quit smoking. Smoking can reduce blood flow to the feet. 

Daily Foot Care

  • Inspect feet daily/regularly: Get into a regular routine. Check between toes along with the surfaces of the foot. If you have reduced sensation, use a large mirror to look at your feet for problems. If you cannot check on your own, ask for help from a family member or friend. Look for cuts, sores, blisters, corns, calluses, or any redness or hot spots. 

  • Wash feet daily: After a bath or shower is a good time to do daily foot care. Make sure the water is not too hot (90 to 95 degrees F is safe). Do not soak feet. Dry feet well. Rub a small amount of skin lotion or cream on the tops and bottoms of feet to keep the skin moist and healthy. Do not put lotion or cream between toes.

  • Smooth corns and calluses gently: Talk with a primary care provider or a podiatrist (foot specialist) about how to deal with corns and calluses if they are problematic. Do not use scissors or other tools to cut them off.  Using a pumice stone after bathing to gently rub the skin in one direction to gently smooth these down may be helpful.

  • Trim toenails straight across with a toenail clipper: Trim toenails after bathing. The nails will be softer and easier to cut. Don’t cut too close or into the corners and avoid breaking any skin. If you have reduced sensation or can’t see or reach your toenails to cut them, find someone to help or seek out a podiatrist to do this.

  • Purchase well-fitting shoes: Buy shoes that cushion the feet, distribute pressure evenly, have a broad and square toe box, laces with three to four eyes per side and a padded tongue. Make sure they are  made of lightweight materials. Walking or athletic shoes are best. Avoid vinyl or plastic shoes, and shoes with pointed toes. When buying new shoes, try them on at the end of a day when your feet are at their largest. Make sure there is room at the toes and around the sides; break in new shoes slowly. If you have an existing foot problem, you may need extra wide or deep shoes. If this problem caused a deformity (see above for common foot deformities), therapeutic shoes that are custom-molded to relieve pressure from a particular area of the foot or feet may be required. These may be covered by health insurance plans or Medicare

  • Wear closed toe shoes and socks as often as possible: Try not to walk barefoot or just with toe coverings on. Buy toe coverings (e.g., socks, stockings) with no seams. There are special socks designed for people with diabetes, and socks that can monitor the temperature of your feet. Talk to a  healthcare provider about these products before  making a purchase.  

  • Protect feet from temperatures that are too hot or cold: If you have reduced sensation in your feet, check the temperature of your skin with your fingers or elbow. Wear shoes if the surface you walk on will be hot. Use sunscreen on your feet to avoid sunburn. Keep feet away from heaters and open fires. In cold weather, use socks and lined boots to keep your feet warm. 

  • Keep blood circulation flowing: Put feet up on a stool rather than letting them dangle or rest on the floor. Get up and move regularly. Wiggle your toes. Roll your ankles around.  

  • Contact a healthcare provider or foot doctor for a foot problem that is not healing or is getting worse – a small foot problem can rapidly become a big foot problem. 

Annual or As Needed Actions

  • Talk to your provider about any history of foot problems along with any current problems. 

  • Get feet checked at every healthcare provider visit. To make sure feet get examined, take your shoes and socks off when in the exam room and ask for a foot check to be done. 

  • At least annually make sure a healthcare provider completes the actions below, considered a comprehensive foot exam: 

  • Asks about and looks for signs and symptoms of a foot problem.    

  • Looks at the skin on feet and lower legs as well as the shape of the feet. 

  • Asks if you are able to complete routine self-care for feet. If not, develop a plan to make sure this can get done. This may include a referral to a foot care specialist (podiatrist).  

  • Feels skin for temperature or uses a pin to prick (not pierce) the skin on legs, feet and hands to assess small fiber function. 

  • Checks pedal pulses (on the top of the foot or behind the ankle bone.)

  • Uses a tuning fork that applies vibration on the skin to assess large fiber function. 

  • Uses a monofilament on several points of the feet to determine if they have sufficient sensation (feeling) or are at risk for problems due to lack of feeling (nerve) or reduced circulation. (A monofilament is a thin, yet stiff strand of nylon attached to a plastic base.)   

If you are told you have indications of diabetes-related neuropathy or reduced circulation in your lower legs and feet, use the list above to check and keep your feet healthy. If you detect a foot problem, act quickly to have the problem evaluated and put a treatment plan in place with a healthcare provider. 

Insight from a person with diabetes 

Clare Tuson, who has had type 1 diabetes for over 47 years, shared some of her insights on the practical and emotional aspects of diabetes-related foot problems.

Tuson, 61, is a PODS (Part of DiabetesSisters) Meetups leader in MetroWest Boston. In addition to volunteering for DiabetesSisters, Tuson puts her feet into action playing tennis, riding her bicycle, and going on long walks and hikes. 

Her awareness about the need to do regular foot care was raised when, in 2014, she signed up to participate in a clinical trial testing a C-peptide replacement hormone to treat diabetic peripheral neuropathy. 

“Indeed, a nerve conduction velocity test completed for the study, showed I did have peripheral diabetic neuropathy,” Tuson said. After a year of weekly injections of the study drug and visiting the clinic, she said, the drug did not show improvement in nerve conduction and was scrapped. 

“However, the diagnosis of diabetic peripheral neuropathy encouraged me to take better care of my diabetes and pay more attention to my feet,” Tuson said. 

She still checks her feet in the shower every day and wears shoes that fit comfortably. Also, she asks her endocrinologist at routine visits to check her feet because, in her experience, it's not a usual part of the exam. Tuson has access to a podiatrist and consults this member of her healthcare team if she develops a foot problem. 

“Having been diagnosed in the days of people having to do urine sugar testing and [taking] insulin made from pigs, I’m very grateful for the new technologies and products to help me live my best life,” Tuson said. “I realize it’s on me to keep my [feet] in good shape and live a healthy lifestyle.”

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About the authors

Hope Warshaw, MMSc, RD, CDCES, BC-ADM, is a nationally recognized registered dietitian and certified diabetes care and education specialist. She has spent her career, now spanning more than 40 years,... Read the full bio »