The Diabetes-Foot Warning Nobody Talks About Until It's Serious
- t2diabetesnetwork
- 3 days ago
- 3 min read
Written by Clare Koning, RN, PhD 5 min read
Key Highlights
✅ Diabetic foot ulcers affect up to 25% of people with diabetes in their lifetime
✅ Peripheral neuropathy, present in up to 50% of people with T2D
✅ The 2026 ADA Standards of Care now incorporate neuropathy screening
✅ Preventive foot care education reduces ulcer and amputation rates by up to 50%
✅ The gap between knowing and doing remains enormous
A foot ulcer that begins as a blister, a small cut, or a pressure sore that you simply could not feel. An infection that progresses within days without the pain signals that would normally drive you to seek help. A trajectory that leads, in the most serious cases, to amputation.
In Canada, adults with diabetes are over 20 times more likely to undergo a non-traumatic lower limb amputation than the general population, and 85% of those amputations are preceded by a foot ulcer. Up to 25% of people with diabetes will develop a foot ulcer in their lifetime.
These are not inevitable outcomes. They are largely preventable with early recognition, proper self-care education, and appropriate clinical surveillance.
Why Feet Are So Vulnerable in T2D
The specific vulnerabilities of the diabetic foot stem from two interconnected processes: neuropathy and vascular disease.
Peripheral neuropathy, nerve damage caused by prolonged elevated blood sugar, is present in up to 50% of people with T2D. It affects the longest nerves in the body first, those running from the spine to the feet. The result is a gradual loss of protective sensation: the ability to feel pain, pressure, temperature, and position in the feet. A stone in a shoe, a too-tight sock seam, a blister from ill-fitting footwear, all can cause persistent injury that the person cannot feel and therefore does not address.
The ADA's 2026 Standards of Care note that peripheral sensory neuropathy is the single most common contributing cause of foot ulceration, present in 78% of cases. The triad of neuropathy, minor trauma, and foot deformity was identified in over 63% of study participants with ulcers.
Concurrent peripheral artery disease (PAD), reduced circulation to the legs and feet caused by atherosclerosis that is more common and more aggressive in T2D, further compromises healing. When tissue is already oxygen-deprived and an injury occurs without sensation to trigger attention, the conditions for rapid deterioration are set.
What the 2026 Guidelines Changed
The 2026 ADA Standards of Care strengthened the narrative around foot complication prevention and updated neuropathy assessment to incorporate the Ipswich Touch Test alongside the established 10-gram monofilament test. Both tests are simple, non-invasive, and can be performed in a primary care setting in under two minutes.
The guidelines recommend that all people with T2D be assessed for peripheral neuropathy starting at diagnosis, and annually thereafter. They also recommend comprehensive foot examinations at least annually, with more frequent checks for people with identified risk factors including neuropathy, previous ulcers, or smoking history.
The updated guidelines also reference structured preventive foot care education as reducing ulcer and amputation rates by up to 50%, a finding that positions patient education not as a nice-to-have but as a clinical intervention.
What Daily Foot Care Actually Looks Like
Many people with T2D have been told, in abstract terms, to "take care of your feet." Fewer have been given specific, practical guidance on what this means.
The ADA guidelines recommend daily visual inspection of the entire foot, including between the toes and on the sole, using a mirror if necessary. Wash feet daily in lukewarm water tested with the elbow, not the foot, to avoid burns. Dry thoroughly, especially between toes. Moisturise dry skin but avoid applying cream between the toes, where moisture can promote fungal infection. Never walk barefoot, even indoors. Check inside shoes for foreign objects before putting them on. Wear well-fitting, cushioned footwear and replace worn soles.
Any new callus, blister, redness, swelling, cut, or wound that is not healing should be evaluated promptly, without waiting to see if it gets better on its own.
The gap between knowing this and doing it daily is where most preventable amputations originate. A two-minute evening routine changes that.
When to See a Specialist
Annual foot examination with a podiatrist is recommended for all people with T2D. More frequent specialist involvement is indicated for anyone with identified neuropathy, previous ulceration, amputation, PAD, or who smokes.
If you have never had a formal foot examination or have not had one in the past year, this is worth raising at your next appointment. It is a standard of care, not an optional extra.
For more on diabetes complications and prevention, visit the T2D Network's Learn More page.