Diabetes is a major problem in the United States. Individuals with diabetes have a 30-fold higher risk of undergoing an amputation (1). There are many different types of foot problems that can occur secondary to diabetes.
It’s important to be aware of what can happen to your feet when you have diabetes and what you can do to better take care of your feet. This can help prevent infections and amputations.
In this article, we’ll discuss the major foot problems that are commonly seen in people with diabetes and the actionable steps you can take for each of them.
Let’s dive in…
1) Diabetic neuropathy
Neuropathy is one of the biggest problems that can occur from diabetes. When you have elevated blood sugar levels for a prolonged period, this can cause nerve damage to occur. Neuropathy is said to be present to some degree in more than 50% of diabetic persons older than 60 years (2).
Neuropathy may feel like:
- Burning pain
- Tingling pain
- Feeling a “leathery” type feeling in the feet
- Feeling as if you have socks on your feet even when barefoot
- Inability to differentiate between hot and cold
- Toes may feel cold or hot
- Prickling feel in the feet
You may notice subtle neuropathy symptoms start in your toes and then progress into your foot. This can happen slowly within a few months to a few years. This can be a major problem, as neuropathy is often not reversible.
If you can’t feel the bottoms of your feet, you are at higher risk for foot problems. Some of the common issues you may encounter if you have foot neuropathy are:
- Blister formation
- Ulcer formation
- Athletes foot
- Foot fissures
In someone who doesn’t have neuropathy, their body signals notify them when there is a problem with their feet. Say for instance you develop a foot infection…if you have full sensation, your body alerts you to the infected area by activating pain signals.
People who have neuropathy, may not even feel any discomfort associated with an infection or ulceration.
Read more about nerve pain in The Ultimate Guide To Nerve Pain On The Foot.
What You Can Do
- Check your feet every day
This may seem like common sense, but you would be surprised how many people do not check their feet regularly. When you check your feet, you should be checking not just the top of your feet, but also the bottom of your feet. You should be checking for any cuts and scrapes on your feet.
It’s also very important to check in between your toes. Sweat can accumulate in between the toes, which can cause a fungal infection to occur. Avoid walking barefoot in communal public areas like gyms and locker rooms.
Pro tip: The most common area where sweat accumulates is between the fourth and fifth toes. Make sure you check that area regularly! If you see white, wet (macerated) tissue, you will want to contact your doctor for a prescription antifungal to help clear this.
Fungus is contagious. Immunocompromised people and diabetics tend to pick up fungus more easily. The fungus can look scaly in moccasin distribution on the bottom of your feet.
It can also look red and may be itchy. If you have fungus in your feet you can start by using a topical antifungal like Lamisil 1% cream. If the fungus has not improved, it’s best to be evaluated by your doctor for prescription antifungal.
Read more about How to Prevent Foot Fungus From Spreading And Recurring in this post.
- Check for any signs of infection in the feet
Infection can occur anytime in the feet. It can occur even from a small cut on the skin. When you check your feet every day, look for any signs of redness in the skin, swelling, heat, pain, pus, or streaking red lines going up the foot.
This could indicate that you have an infection and you will need to contact your doctor immediately. Your doctor may want to give you an antibiotic.
If you do notice an infection on your foot and are waiting to see the doctor, keep the area clean and apply an antibiotic cream to the area and keep it covered with a dry dressing.
Make sure not to soak your feet in peroxide and don’t use any acids on your feet.
You will also want to check on yourself and see if you are feeling well. If you are feverish, feeling nauseous, and vomiting, you will need to contact your doctor. Sometimes when an infection is severe, it can cause those systemic signs to occur.
- Check your footwear
In patients with neuropathy, footwear is incredibly important. When you do not have sensation in your feet, you cannot tell whether or not a certain pair of shoes is uncomfortable. If you wear shoes that are not designed for your specific foot structure, you may develop blisters and ulcerations. This can then get infected.
Say for instance you have hammertoes and bunions in your feet. If you wear shoes that are too narrow or have a shallow toe box, you may get painful calluses and corns that can then turn into ulceration.
Another example would be if you are wearing shoes that are too tight. You may notice pressure ulcerations develop on your feet from the tight shoe rubbing against the skin.
You will also want to make sure that your shoes are not too loose. This can cause blister formation especially if the shoe is loose in the heel area.
The best thing to do would be to see your foot doctor get prescription diabetic shoes and diabetic inserts. Sometimes insurance may cover this yearly if you have diabetes with neuropathy.
Diabetic shoes are designed to be extra-depth to accommodate your foot deformities. Most diabetic shoes also have a deep toe box, meaning that there is extra room allotted for your toes. This will avoid pressure on the top of your toes.
In addition, diabetic shoes have a thick sole on the bottom to support you when walking. This can protect your feet as you walk.
People with diabetes may have neuropathy in their fingers which can make it difficult to tie shoelaces. Certain diabetic shoes have Velcro straps and no-tie laces which can help with this issue. This can be so helpful!
If diabetic shoes are not covered by your insurance, it may be a good idea to check your local shoe store to see if they sell diabetic shoes. You can also check out websites like healthyfeetstore.com where you can buy diabetic shoes after being appropriately measured.
If you need to get your feet measured, you can go to a shoe store to have them measured. It’s best to go at the end of the day when your feet are the most swollen.
If you want to measure your feet on your own, you can obtain a Brannock device and measure your feet this way. Check out this video by San Luis Podiatry on how to measure your feet using a Brannock device.
After obtaining the shoes, you will want to try them on and walk around in them for a bit to make sure they are the right fit for you. Remember, this is very important to ensure proper fit.
Diabetic inserts (plastazote) are very beneficial in people with diabetic neuropathy. Diabetic inserts can be custom-made as well.
Say for instance you develop ulcerations regularly in the ball of your feet. A metatarsal pad can be incorporated into the diabetic insert to take pressure off the ball of your foot.
Diabetic inserts ideally should be 6 mm to 10 mm in thickness (5). They are made of softer material and can be worn to help prevent sheer and blister formation. The insert disperses forces throughout the foot when you’re walking so that you’re not putting pressure in one spot. This is very important when you have neuropathy in your feet.
You will need a prescription for a custom diabetic insert. If your insurance doesn’t cover this, you can obtain over-the-counter diabetic inserts. Ideally, you are looking for a multi-density insole, which means plenty of cushion. You will want to avoid inserts that are too thin.
What About Running Shoes?
Believe it or not, running shoes can be beneficial in people who have diabetes with neuropathy. Most running shoes have stiff soles in them with forgiving toe boxes. Running shoes are beneficial in patients with diabetes.
Other Tips for Neuropathy
Lastly, if you suffer from neuropathy and can’t reach down to look at the bottoms of your feet, have a family member or friend help you. If you live alone, you can put a mirror against a wall and check the bottoms of your feet that way.
If you have diabetes with neuropathy, you should be seeing your family doctor or foot doctor every 3 to 6 months so they can perform a foot exam and make sure that your feet are in good health.
They will check your sensation using a Semmes-Weinstein Monofilament Wire 5.07g/10 to check your ability to perceive 10g of pressure. Your doctor may also check vibration sensation by applying a vibrating tuning fork on your foot. If you have difficulty feeling either of these two things, you have neuropathy.
Your doctor may also want to check reflexes as well as check your gait to see if you struggle with balance issues, as this can be a problem with neuropathy as well. Your doctor may suggest physical therapy if this is the case.
Diabetics who have calluses are at high risk for ulcer development, especially if they have neuropathy.
Calluses are thickened areas of skin that the body develops to try to protect itself against repetitive pressure. A lot of people get calluses, but they never turn into ulcers.
So what makes diabetics more likely to have calluses that develop into ulcerations?
PW Brand hypothesized that a person with full sensation in their feet subconsciously can perceive inflammation in the feet and alter their gait to redistribute pressure when walking. However, people with neuropathy aren’t able to alter their gait to redistribute pressure because of their inability to perceive sensation in their feet (4).
This is a problem because if you aren’t aware that there is an issue in your foot due to numbness, then you can’t fix it. This repeated pressure in a specific area of your foot can cause ulceration to form.
Although some ulcerations can occur as a result of injury, most occur due to chronic, repetitive pressure in an area over time.
Your doctor will treat your ulcer regularly with debridement and appropriate wound care.
You can read all about Diabetic Foot Ulcers here.
What You Can Do to Prevent Calluses/Ulcerations
As I mentioned before, diabetic shoes and inserts would be greatly beneficial. However, if you are looking for padding, you can use offloading donut pads to take pressure away from callus areas. This can help prevent the breakdown of the skin.
There are also toe pads that you can apply on your toes to prevent corns, especially when wearing shoes.
Metatarsal pads also work well to take pressure off the ball of your feet. Make sure you are applying them correctly. Metatarsal pads should be situated right underneath your knuckle bones so that they can offload your knucklebones appropriately.
You can watch a video here by NorthWest Foot and Ankle on how to apply them properly. They can be applied to your feet directly or your shoe liners.
3) Peripheral Vascular Disease
Peripheral vascular disease is often seen in people who have diabetes. Peripheral vascular disease is when there is narrowing or blockage of arteries that supply your feet.
Diabetics who have peripheral vascular disease need to be aware of the risks associated with this. Say for instance you have a foot ulcer. Poor blood flow to the ulceration site can slow wound healing.
In addition, PVD in itself can cause ulcers themselves, such as arterial ulcers. These ulcers can be painful and can eventually lead to tissue death (gangrene).
When the peripheral vascular disease is severe, you may notice cramping in your calf muscles that occurs while walking or at rest.
You will need to get regularly checked by your foot doctor if you suspect peripheral vascular disease. Your doctor will check your foot pulses and how strong they are.
If your doctor suspects that you have the peripheral vascular disease they may order a non-invasive test called an Ankle Brachial Index (ABI) to assess the blood flow in your feet.
If there’s further blockage noted on this test, your doctor may suggest you go to a Vascular Surgeon to have further imaging done and possibly even surgery to improve your blood flow.
Make sure you check your feet regularly. If you notice that there is a toe that is turning blue or black, you should contact your doctor immediately.
Avoid smoking if you can, as this makes the peripheral vascular disease worse.
4) Ingrown Toenails
A lot of people get ingrown toenails. However, for diabetics, ingrown toenails can get easily infected due to lack of sensation in the feet. Ingrown toenails can occur due to wearing shoes or even socks that are too tight causing impingement of the nail.
If you have a constant impingement of the skin next to the nail, you can develop a bacterial infection. If this occurs, you will need to see your doctor undergo ingrown toenail surgery and receive an antibiotic.
Do not try to cut out your ingrown toenail yourself as this can make it worse. Until you see the doctor, you can keep the nail border clean with soap and water and apply antibiotic cream with a dry dressing to the area. Avoid soaking in peroxide and avoid getting the area dirty.
To read about Ingrown Toenail Surgery, check out this post.
What You Can Do to Prevent Ingrown Toenails
Make sure your shoes and socks have plenty of wiggle room for your toes. In addition, it’s important to not cut your nails too short or in a curved manner.
A good rule of thumb is to let the toenail grow 2 mm past the nail bed and cut the nail straight across. If you have difficulty cutting your toenails because of toenail fungus, it’s best to see your foot doctor and have them assist you with this.
If you’re diabetic, you are more prone to developing dry flaky skin on the bottoms of your feet. You may also notice thinning of your skin, hair loss, dryness, cracks, and increased callus formation (3). This is due to the autonomic nervous system. With dry feet come heel fissures. It’s very important to take care of heel fissures because if they are not taken care of properly, they can turn into ulcers and become infected easily.
Heel fissures are difficult to treat because it takes consistent management. There is no one-time cure for heel fissures.
Read about how to treat heel fissures in this post.
How You Can Take Care of Dry Skin on Your Feet
You will want to make sure to use a pumice stone gently to remove dead skin from the bottom of your feet. Even Vaseline and pure coconut oil can be beneficial to moisturize the skin.
You can also obtain Diabetic Foot Miracle Cream, which has urea in it. Urea is keratolytic that breaks down the hard keratin in the skin, which in turn will soften the skin.
Pro tip: Applying moisturizer under occlusion can be beneficial. For instance, you can apply Vaseline on your feet and then wrap them with Saran wrap for a few minutes. This will lock in moisture.
If you struggle with very dry feet, you can talk to your doctor about obtaining a prescription for Urea cream. Avoid doing foot soaks, especially in Vinegar, as this can dry the feet out even more!
When you have diabetes, it’s important to protect your feet from excessive heat and excessive cold. Little things can impact your feet in a big way.
If you are going out in the sun, make sure you wear sunscreen. Do not walk barefoot on any hot surfaces.
People who have diabetes in their feet often have diabetes in their fingers and cannot feel whether the water is hot when showering. It’s best to use your elbow to test the water temperature. Be careful when cooking so as not to burn yourself.
Some diabetics use TENS units to help with neuropathy pain. You will need to follow instructions carefully using a TENS unit, as occasionally it can cause burns if left on the skin for too long.
In the cold winter months, you will want to make sure to keep an extra eye on your feet. Don’t walk barefoot and make sure to wear appropriate socks and shoes.
Do not use space heaters to warm your feet. If you need to, you can double up on your socks to keep your feet warm. Electric heated blankets should be avoided.
7) Charcot foot
If you have diabetes with neuropathy, you may develop Charcot foot. This is a condition where the bones of your feet break down and fracture due to neuropathy. There’s also another theory that hyperemia (increased blood flow) to the foot causes resorption and breakdown of the bone.
The exact cause of Charcot foot is not clearly understood. However, up to 50% of individuals with a Charcot foot can recall an injury to the foot (3).
If you sustain multiple fractures to your foot bones, this can cause your foot to collapse. Your foot may also start to develop a “rocker bottom” contour. This combined with neuropathy can be a big problem as this can make you more prone to developing an ulcer on the bottom of your foot.
If you notice that your foot structure is changing (flattening), it’s best to contact your doctor right away. Your doctor may suggest that you stay off of the foot or may suggest custom diabetic shoes, inserts, or a specialized custom offloading boot called a CROW walker.
Occasionally, surgery may be needed for this condition to prevent further breakdown of the bones.
In conclusion, diabetic foot care is so important to prevent major problems in your feet. You can use these simple solutions listed to help prevent foot problems associated with diabetes. When they do occur, the sooner you can address these issues the better. Taking care of your feet can help prevent long-term complications from diabetes.
Have you ever had foot problems from diabetes? I would love to hear your thoughts! Leave a comment.
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