Diabetes-related foot ulcers are among the most consequential complications of diabetes. They precede the large majority of lower-extremity amputations, and they carry substantial morbidity and mortality. Because the underlying drivers—neuropathy, deformity, repetitive pressure and impaired circulation—are identifiable well before a wound appears, prevention is one of the most evidence-supported opportunities in diabetes care. This article summarizes what recent research shows about risk identification, daily self-monitoring, and the prevention of recurrence.
Why Prevention Matters: The Scale of the Problem
A global meta-analysis by Zhang and colleagues (Annals of Medicine, 2017) estimated that about 6.3% of people with diabetes have a history of foot ulceration. In their influential review in the New England Journal of Medicine (2017), Armstrong, Boulton and Bus reported that the lifetime risk of a foot ulcer among people with diabetes is as high as 19% to 34%. The same review highlighted that ulcers frequently return: roughly 40% of patients have a recurrence within one year of healing, with cumulative recurrence approaching 60% at three years and 65% at five years.
These figures reframe how a healed ulcer should be understood. Rather than a resolved problem, a healed ulcer marks the start of a period of “remission” in which the underlying risk persists, and the review authors argued that care should be organized around keeping the foot in remission.
Identifying Who Is at Risk
Annual screening and risk stratification
The International Working Group on the Diabetic Foot (IWGDF) 2023 guideline on the prevention of foot ulcers (Bus et al., Diabetes/Metabolism Research and Reviews) recommends that every person with diabetes be screened at least annually for loss of protective sensation and peripheral artery disease, and that foot deformity, prior ulceration or amputation, and end-stage renal disease be documented. People are then assigned to a risk category, which determines how often the feet should be examined—from once a year in those at lowest risk to every one to three months in those with prior ulceration or amputation.
What a risk-based examination includes
A complete examination covers inspection of the skin and nails for callus, blisters, fissures and pre-ulcerative lesions, assessment of foot shape and joint mobility, testing of sensation (for example, with a 10-g monofilament plus a second test such as vibration perception), and palpation of pedal pulses. The guideline emphasizes that callus is a strong marker of excessive local pressure and that its removal by a trained clinician is part of routine preventive care.
Daily Self-Monitoring and Education
Because neuropathy removes the pain that would normally prompt a person to act, structured education is a core component of prevention. The IWGDF guideline advises that education be delivered in a repeated, practical format—covering daily inspection, appropriate washing and moisturizing, avoiding barefoot walking, and prompt reporting of any new blister, cut or discoloration—rather than as a single information session.
Home skin-temperature monitoring has attracted particular attention. In a randomized trial of 173 high-risk patients, Lavery and colleagues (Diabetes Care, 2007) found that ulcer recurrence over 15 months was 8.5% among participants who used an infrared thermometer to compare the temperature of corresponding sites on each foot, compared with about 29% to 30% in the standard-care and structured-examination groups. A subsequent meta-analysis by Golledge and colleagues (Diabetes/Metabolism Research and Reviews, 2022) pooled such trials and reported a relative risk of foot ulceration of 0.51 (95% CI 0.31–0.84) with temperature monitoring, although the authors graded the certainty of the evidence as low and noted that adherence strongly influences benefit.
Protecting the Foot From Pressure and Recurrence
Footwear is the other pillar of secondary prevention. The IWGDF guideline recommends that people with a healed ulcer use therapeutic footwear with demonstrated pressure-relieving properties, and that it be worn consistently, including indoors. Among the interventions reviewed, custom-made footwear designed with pressure measurement and verified for offloading performs better than generic shoes, but only when it is actually worn; observational work has repeatedly shown that low adherence undermines the benefit. For selected patients, surgical correction of deformity or tendon lengthening may be considered when conservative measures fail.
Effective prevention therefore depends on three linked elements: accurate risk classification, an informed patient who inspects the feet daily, and footwear that is both appropriate and consistently used.
Key Takeaways
Foot ulcers are common, and recurrence after healing is the rule rather than the exception. Annual screening with risk-based follow-up identifies who needs closer surveillance; repeated, practical education supports daily self-inspection; home temperature monitoring appears to lower ulcer incidence in high-risk patients, albeit with low-certainty evidence; and consistently worn therapeutic footwear reduces mechanical stress. Together these measures form the basis of current international guidance on keeping people with diabetes ulcer-free.
References
- Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376(24):2367-2375.
- Bus SA, Sacco ICN, Monteiro-Soares M, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2024.
- Golledge J, Fernando ME, Alahakoon C, et al. Efficacy of at home monitoring of foot temperature for risk reduction of diabetes-related foot ulcer: a meta-analysis. Diabetes Metab Res Rev. 2022;38(6).
- Lavery LA, Higgins KR, Lanctot DR, et al. Preventing diabetic foot ulcer recurrence in high-risk patients: use of temperature monitoring as a self-assessment tool. Diabetes Care. 2007;30(1):14-20.
- Zhang P, Lu J, Jing Y, et al. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Ann Med. 2017;49(2):106-116.
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