A healed diabetic foot ulcer is not the end of the story. Across the published literature, roughly 40% of people whose ulcer has closed will develop another one within a year, and around 60% will do so within three years. Because of this pattern, specialists increasingly describe a healed ulcer not as “cured” but as being in remission — a term borrowed deliberately from oncology to signal that the underlying disease process persists and that structured surveillance is required (Armstrong, Boulton & Bus, New England Journal of Medicine, 2017).
Why the Language of Remission Matters
The factors that produced the first ulcer — loss of protective sensation, foot deformity, limited joint mobility, abnormal plantar pressure, and often peripheral artery disease — are still present the day the wound closes. Newly healed skin is also mechanically inferior to intact tissue and tolerates repetitive stress poorly.
Framing this period as remission changes clinical behaviour. It reframes the goal from wound closure to the long-term maintenance of an intact foot, and it justifies ongoing follow-up in patients who feel well and, because of neuropathy, feel nothing wrong.
Where and When Ulcers Recur
Recurrence is not simply a matter of the old wound reopening. In a multicentre analysis of 129 patients in diabetic foot remission, only 17% of subsequent ulcers appeared at the same anatomical site as the previous one, while 48% occurred on the contralateral foot (Petersen et al., Journal of Foot and Ankle Research, 2020). More than 60% of participants had wounds at more than one plantar location by the end of follow-up. The clinical implication is direct: surveillance and pressure management must cover both feet in their entirety, not just the previously ulcerated site.
Timing matters as much as location. A separate analysis of 300 patients found that ulcers were identified at roughly 2.8 times the expected rate during the weeks when routine appointments were scheduled, implying that many wounds develop unnoticed between visits. The authors estimated an average delay of about 15 days between ulcer development and identification (Petersen et al., BMJ Open Diabetes Research & Care, 2020). In a neuropathic foot, two weeks of unrecognised tissue breakdown can be the difference between a superficial lesion and a deep, infected wound.
What the Evidence Supports for Prevention
The 2023 International Working Group on the Diabetic Foot (IWGDF) prevention guideline synthesises this evidence into a set of graded recommendations (Bus et al., Diabetes/Metabolism Research and Reviews, 2023). Its core elements include annual screening for loss of protective sensation and peripheral artery disease in those at very low risk, with more frequent screening at higher risk levels; structured education on foot self-care and never walking unprotected; and prompt treatment of any pre-ulcerative lesion, such as callus, blister, or haemorrhage under callus.
Footwear That Demonstrably Reduces Pressure
The guideline specifically recommends prescribing therapeutic footwear with a demonstrated plantar pressure-relieving effect during walking to prevent recurrence — not merely footwear labelled as diabetic or accommodative. In-shoe pressure measurement allows footwear to be verified and modified rather than assumed effective. Adherence is the limiting factor: pressure relief only works during the steps in which the footwear is actually worn, which is why indoor footwear and daily wear patterns are legitimate clinical targets.
Home Skin Temperature Monitoring
Inflammation precedes visible breakdown, and a localised rise in plantar skin temperature can flag imminent tissue damage. In the DIATEMP multicentre randomised controlled trial of 304 participants, daily home temperature measurement did not significantly reduce recurrence at the primary outcome sites overall (29.1% versus 37.3%; RR 0.78, 95% CI 0.57–1.08). However, it did significantly reduce recurrence at any foot site (RR 0.76, 95% CI 0.58–1.00), and among participants who actually reduced their walking activity when a hotspot appeared, recurrence fell substantially (RR 0.34, 95% CI 0.11–0.99) (Bus et al., BMJ Open Diabetes Research & Care, 2021). The signal is only useful if it is acted upon.
Activity, Surgery, and Integrated Care
The IWGDF also suggests supervised foot-ankle exercise programmes for those at low-to-moderate risk, notes that an increase of approximately 1,000 steps per day is likely safe with respect to ulcer risk, and supports flexor tendon tenotomy for non-rigid hammertoe with a pre-ulcerative lesion. It advises against nerve decompression procedures for ulcer prevention. Above all, it recommends integrated foot care — combining professional treatment, education, and footwear — for moderate-to-high-risk patients. A UK Health Technology Assessment review reached a compatible conclusion, finding digital infrared thermometry, complex multi-component interventions, and therapeutic footwear with offloading to be effective, while noting persistent uncertainty about which patients benefit most (Crawford et al., Health Technology Assessment, 2020).
Measuring What Matters
Because healing rates alone do not capture long-term outcomes, some groups advocate tracking ulcer-free, hospital-free, and activity-rich days as the metrics that reflect what remission is actually meant to deliver (Khan & Armstrong, Journal of Wound Care, 2018). These measures capture the trade-off inherent in prevention: immobilising a patient reduces plantar stress but erodes function, cardiovascular health, and quality of life.
Clinical Summary
Diabetic foot ulcer recurrence is common, frequently occurs on the opposite foot, and is often detected late. The evidence base supports continued risk-stratified screening after healing, education, prompt treatment of pre-ulcerative lesions, pressure-verified therapeutic footwear worn consistently, and home temperature monitoring coupled with a clear action plan when a hotspot appears. Remission is a state that has to be actively maintained rather than a milestone that has been passed.
References
- Armstrong DG, Boulton AJM, Bus SA. Diabetic Foot Ulcers and Their Recurrence. New England Journal of Medicine. 2017;376(24):2367–2375. doi:10.1056/NEJMra1615439
- Bus SA, Sacco ICN, Monteiro-Soares M, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2023;40(3):e3651. doi:10.1002/dmrr.3651
- Bus SA, Aan de Stegge WB, van Baal JG, Busch-Westbroek TE, Nollet F, van Netten JJ. Effectiveness of at-home skin temperature monitoring in reducing the incidence of foot ulcer recurrence in people with diabetes: a multicenter randomized controlled trial (DIATEMP). BMJ Open Diabetes Research & Care. 2021;9(1):e002392. doi:10.1136/bmjdrc-2021-002392
- Petersen BJ, Rothenberg GM, Lakhani PJ, et al. Ulcer metastasis? Anatomical locations of recurrence for patients in diabetic foot remission. Journal of Foot and Ankle Research. 2020;13:1. doi:10.1186/s13047-020-0369-3
- Petersen BJ, Bus SA, Rothenberg GM, Linders DR, Lavery LA, Armstrong DG. Recurrence rates suggest delayed identification of plantar ulceration for patients in diabetic foot remission. BMJ Open Diabetes Research & Care. 2020;8(1):e001697. doi:10.1136/bmjdrc-2020-001697
- Crawford F, Chappell FM, Lewsey J, et al. Risk assessments and structured care interventions for prevention of foot ulceration in diabetes: development and validation of a prognostic model. Health Technology Assessment. 2020;24(62):1–198. doi:10.3310/hta24620
- Schaper NC, van Netten JJ, Apelqvist J, et al. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2023;40(3):e3657. doi:10.1002/dmrr.3657
- Khan T, Armstrong DG. Ulcer-free, hospital-free and activity-rich days: three key metrics for the diabetic foot in remission. Journal of Wound Care. 2018;27(Sup4):S3–S4. doi:10.12968/jowc.2018.27.Sup4.S3
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