Achieving wound closure in a diabetic foot ulcer (DFU) is often treated as the clinical endpoint, yet a substantial body of evidence shows that healing is rarely the end of the story. Diabetic foot ulceration behaves as a chronic, relapsing condition rather than a discrete event, and a large proportion of patients who achieve closure go on to develop a new ulcer, frequently within the first year. Understanding who is most likely to experience recurrence, and how surveillance should be structured once a wound has healed, is central to reducing the downstream burden of infection, hospitalization, and amputation.
The Scale of the Recurrence Problem
In a widely cited review published in the New England Journal of Medicine, Armstrong, Boulton, and Bus (2017) reported that roughly 40% of patients with a healed diabetic foot ulcer develop a new ulcer within one year, rising to about 60% by three years and 65% by five years. These figures reframe the DFU care pathway: rather than a single episode to be resolved, ulceration is better understood as a condition managed in cycles of active disease and remission, similar to other chronic relapsing conditions.
More recent data support this pattern. A 2025 meta-analysis by Lin and colleagues in PLOS ONE pooled outcomes from more than 5,000 patients and found an overall recurrence rate of approximately 35% during follow-up, broadly consistent with the earlier estimates once differing follow-up durations are accounted for.
Which Patients Are Most Likely to Recur
The same 2025 meta-analysis identified nine factors significantly associated with recurrence. Peripheral arterial disease carried the strongest association, with more than a threefold increase in risk, followed by foot deformity (roughly 2.5-fold) and a plantar ulcer location (roughly 2.4-fold). Living alone, diabetic peripheral neuropathy, retinopathy, nephropathy, male sex, and smoking history were each independently associated with elevated risk, while body mass index and hypertension were not significant in this analysis.
A separate review by Sun and colleagues, published in the Journal of Tissue Viability in 2024, examined predictors of post-healing recurrence across 50 studies and highlighted additional considerations, including loss of protective sensation in the contralateral foot, coexisting cardiovascular disease, glycemic control, and nutritional status. Together, these findings point to recurrence risk as multifactorial, spanning vascular, neurological, biomechanical, and social dimensions rather than any single variable.
Risk Stratification and Recommended Follow-Up Intervals
The International Working Group on the Diabetic Foot (IWGDF) 2023 guideline update on prevention, authored by Bus and colleagues and published in Diabetes/Metabolism Research and Reviews, sets out a four-tier risk classification system intended to guide surveillance frequency after a foot has healed. Individuals with no loss of protective sensation and no peripheral arterial disease are classified as very low risk (IWGDF Risk 0) and are recommended to undergo screening approximately once a year. Those with loss of protective sensation or peripheral arterial disease alone (Risk 1) are advised to be reassessed every six to twelve months, while those with both findings, or with foot deformity in addition to one of these findings (Risk 2), warrant review every three to six months. Patients with a history of a prior ulcer or lower-extremity amputation (Risk 3) fall into the highest-risk category and are recommended to be seen every one to three months.
This stratification is not simply administrative. It reflects the concentration of recurrence risk in a relatively small subgroup of patients: those who have already healed a plantar ulcer are, by definition, in the highest surveillance category and account for a disproportionate share of subsequent ulceration, infection, and amputation events.
Secondary Prevention After Healing
The IWGDF 2023 prevention guideline places particular emphasis on therapeutic footwear with a demonstrated plantar pressure–relieving effect during walking for patients who have healed a plantar ulcer, along with consistent use of that footwear indoors and outdoors. It also supports integrated foot care programs combining professional monitoring, appropriate footwear provision, and structured patient education, rather than relying on any single intervention in isolation. These recommendations align with the broader recurrence literature, which points to biomechanical offloading and consistent long-term follow-up as central to relapse prevention, alongside management of the vascular, neurological, and metabolic risk factors identified above.
Clinical Summary
Diabetic foot ulcer healing does not equate to resolution of underlying risk. Recurrence rates of roughly 40% at one year and two-thirds by five years, corroborated by more recent pooled analyses, indicate that a healed ulcer marks the start of a high-risk surveillance period rather than its conclusion. Peripheral arterial disease, foot deformity, plantar ulcer location, neuropathy, and markers of systemic microvascular disease are consistently identified as the strongest predictors of relapse. Risk-stratified follow-up, ranging from annual review for very low-risk individuals to monthly or bimonthly review for those with a prior ulcer, together with pressure-relieving footwear and structured patient education, forms the evidence-based framework for reducing recurrence in this population.
References
Armstrong DG, Boulton AJM, Bus SA. Diabetic Foot Ulcers and Their Recurrence. New England Journal of Medicine. 2017;376(24):2367-2375.
Bus SA, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3651.
Lin C, Tian J, Zhang Z, Zheng C, Liu J. Risk factors associated with the recurrence of diabetic foot ulcers: A meta-analysis. PLOS ONE. 2025.
Sun Y, Zhou Y, Dai Y, Pan Y, Xiao Y, Yu Y. Predictors of post-healing recurrence in patients with diabetic foot ulcers: A systematic review and meta-analysis. Journal of Tissue Viability. 2024.
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