The majority of diabetes related amputations begin with a small injury that the person did not feel: a stone in a shoe, a blister from new footwear, a cut from walking barefoot.
Most are preventable, and prevention takes about two minutes a day.
Why Diabetic Feet Are Vulnerable
Three problems combine, and it is their combination that is dangerous.
Neuropathy: nerve damage reduces sensation, so injuries go unnoticed. It also affects the nerves controlling sweating, leaving skin dry and prone to cracking, and the nerves to small foot muscles, causing deformity and abnormal pressure points.
Poor circulation: narrowed arteries reduce blood flow, so wounds heal slowly and antibiotics reach the tissue less effectively.
Impaired immunity: high blood sugar impairs white cell function, so infection establishes more easily and spreads faster.
A minor wound in a person without diabetes heals in days. The same wound in a neuropathic, poorly perfused foot can become a deep infection within a week.
Recognising Neuropathy
Nerve damage develops gradually and is often present before it is diagnosed.
- Numbness or reduced sensation, typically starting in the toes and spreading upward
- Tingling or a pins and needles sensation
- Burning pain, characteristically worse at night
- Feeling as though walking on cotton wool
- Not noticing hot surfaces or a stone in the shoe
- Dry cracked skin, particularly at the heels
- Changes in foot shape, with clawing of the toes
Paradoxically, painful neuropathy that later becomes painless is not an improvement. It usually means sensation has been lost further, which increases risk.
The Daily Check
This takes two minutes and is the single most effective preventive measure.
- Look at the whole foot every day, including between the toes and the sole
- Use a mirror on the floor, or ask a family member, if you cannot see the sole
- Look for cuts, blisters, redness, swelling, colour changes and cracks
- Feel for warm areas, which can indicate infection or a developing Charcot foot
- Check for ingrown nails and fungal infection between the toes
- Report anything new the same week, not at your next appointment in three months
Do this at a fixed time, such as before bed, so it becomes routine rather than something remembered occasionally.
The Rules That Prevent Injury
These are specific and each addresses a common cause of ulceration.
- Never walk barefoot, indoors or outdoors, including in the home and at temples. Carry socks or slip on footwear
- Check inside shoes with your hand before wearing them, every time
- Buy shoes in the evening when feet are largest, and break new footwear in gradually
- Wear seamless cotton socks, changed daily, without tight elastic
- Test bath water with your elbow rather than your foot
- Never use hot water bottles or heating pads on the feet
- Do not use corn caps or chemical wart removers, which cause chemical burns in insensate feet
- Do not cut corns or calluses yourself
- Cut nails straight across, not into the corners
- Moisturise the feet but not between the toes, where it encourages fungal infection
Walking barefoot in the house is the most common single cause we encounter, and it is deeply habitual in Indian households, which is why it needs conscious attention.
Footwear Matters More Than People Think
Ordinary chappals and open sandals offer no protection and are a frequent contributor.
Appropriate footwear has a wide deep toe box, cushioned soles, no internal seams pressing on the foot, adjustable fastening, and closed toes for outdoor use.
Where there is deformity, previous ulceration or significant neuropathy, custom insoles or therapeutic footwear redistribute pressure away from high risk areas. This is preventive rather than cosmetic, and it substantially reduces recurrence in people who have already had an ulcer.
Signs Needing Same Day Attention
A diabetic foot problem escalates faster than most people expect. Do not wait for a routine appointment for any of these.
- Any break in the skin that is not healing
- Redness spreading up the foot or leg
- Swelling of one foot
- Warmth or a hot spot
- Discharge, pus or a foul smell
- Black or dark discolouration of any part of the foot
- Fever alongside a foot wound
- New pain in a previously numb foot
- Blood sugar suddenly much harder to control, which can indicate hidden infection
A sudden unexplained rise in blood sugar in someone previously stable is a recognised sign of occult infection, often in the foot. Our emergency service assesses diabetic foot infections urgently.
Charcot Foot
This deserves specific mention because it is frequently misdiagnosed as infection or gout, and the consequences of delay are severe.
In Charcot foot, bones in a neuropathic foot weaken and fracture without significant trauma, and continued walking collapses the arch, producing permanent deformity.
It presents as a hot, red, swollen foot, usually without a wound and often without much pain given the extent of the change. It is easily mistaken for cellulitis.
Treatment requires immediate immobilisation and complete offloading, often in a cast, for months. Continuing to walk during the active phase causes the deformity that later leads to ulceration. Any hot swollen foot in a person with neuropathy should be assumed to be Charcot until proven otherwise.
The Annual Assessment
Everyone with diabetes should have a formal foot examination at least annually, and more often if risk factors are present.
- Testing sensation with a monofilament and tuning fork
- Feeling foot pulses, and measuring ankle brachial index where indicated
- Inspecting for deformity, callus and skin changes
- Assessing footwear
- Risk categorisation, which determines follow up frequency
Anyone with previous ulceration, previous amputation, significant neuropathy or poor circulation should be reviewed every one to three months rather than annually. Our diabetology department runs foot assessment alongside diabetes review.
Check your feet daily, never walk barefoot, check inside your shoes before putting them on, and treat any wound as urgent rather than minor. Those four habits prevent the large majority of diabetic foot complications.
Our diabetes care service at T. Nagar provides foot assessment and wound management.
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