Diabetes Foot Care: Ulcer Prevention and Daily Inspection Checklist

Every year, over 82,000 people in the U.S. lose a foot or leg to diabetes-related amputation. Most of these cases could have been avoided. The key isn't complex surgery or expensive tech-it's a simple daily habit: checking your feet. If you have diabetes, your feet are at risk. Nerve damage hides pain, poor circulation slows healing, and even a small blister can turn into a life-changing ulcer. But here’s the truth: diabetic foot ulcers are preventable. And the most powerful tool you have is a 5-minute daily inspection.

Why Your Feet Are at Risk

Diabetes doesn’t just affect blood sugar. Over time, high glucose levels damage nerves, especially in your feet. This is called peripheral neuropathy. You might not feel a pebble in your shoe, a hot floor, or a cut from trimming your nails. At the same time, blood flow to your feet drops. That means cuts, scrapes, and blisters don’t heal fast. In fact, a minor injury that would vanish in days for someone without diabetes can turn into a deep ulcer in weeks for someone with it.

The numbers don’t lie. About 15% to 25% of people with diabetes will develop a foot ulcer at some point. And once an ulcer forms, the chance of amputation jumps dramatically. The International Working Group on the Diabetic Foot (IWGDF) says 79% of midfoot ulcers and 87% of forefoot ulcers start because of ill-fitting shoes. Barefoot walking-even indoors-increases ulcer risk by more than 11 times. This isn’t fearmongering. It’s data from the CDC and global medical guidelines updated in 2023.

The 5 Pillars of Ulcer Prevention

The 2023 IWGDF guidelines, backed by 37 experts across podiatry, endocrinology, and vascular surgery, outline five non-negotiable steps to prevent ulcers:

1. Identify your risk level
2. Inspect your feet every day
3. Get educated-repeatedly
4. Wear the right shoes
5. Treat modifiable risks like smoking or poor blood sugar

Your risk isn’t the same as someone else’s. The IWGDF uses a simple four-level system:

• Risk 0: No nerve damage, no history of ulcers. You’re low risk, but not immune.
• Risk 1: Nerve damage, but no foot deformity. You need checks every 6 months.
• Risk 2: Nerve damage + foot deformity (like bunions or hammertoes). You need checks every 1-3 months.
• Risk 3: You’ve had an ulcer or amputation before. This is high risk. You need weekly checks and specialist care.

Knowing your level tells you how often to see a doctor. But daily inspection? That’s yours to do-every single day.

The Daily Foot Inspection Checklist

This isn’t a suggestion. It’s a proven protocol used by NYU Langone, the CDC, and the University of Michigan. Do this every day, preferably between 10 a.m. and 2 p.m. when your body temperature is most stable.

1. Wash feet in lukewarm water (90-95°F). Use mild soap. Never use hot water. Test it with your elbow or a thermometer. Nerve damage means you won’t feel scalding.
2. Dry thoroughly. Pay attention to the spaces between your toes. Moisture there invites fungal infections and cracks.
3. Look at every inch. Use a 12-inch mirror or ask someone to help. You need to see the bottom of your feet, the sides, and between toes. Don’t skip the heel or the ball of the foot. That’s where 92% of ulcers form.
4. Check for these signs: Blisters larger than 3mm, cuts deeper than 1mm, redness over 1cm wide, swelling that increases foot circumference by 5% or more, or warmth that feels hotter than the other foot (over 99°F).
5. Moisturize. Use unscented lotion on dry skin-except between toes. Dry skin cracks. Cracks turn into openings for infection.
6. Trim nails straight across. Cut them so they’re 1-2mm above the skin fold. Don’t round the edges. Don’t dig into the corners. Ingrown nails are a leading cause of infection.
7. Don’t walk barefoot. Not even in the house. Not even for 5 minutes. That’s not a rule-it’s a survival tactic.

The CDC found that 68% of ulcers start from unnoticed injuries because inspections were inconsistent. If you skip a day, you’re gambling with your mobility.

Footwear: It’s Not Just About Comfort

Shoes aren’t optional. They’re medical equipment.

For people with Risk 2 or Risk 3, the 2023 IWGDF guidelines say you need therapeutic footwear proven to reduce pressure under the foot by at least 25%. That’s not a fancy label-it’s a measurable standard tested during gait analysis.

Here’s what good diabetic footwear must have:

• 0.5 inches (12.7mm) of space between your longest toe and the shoe tip
• Width that allows your toes to spread naturally (15mm splay)
• A rigid heel counter that doesn’t collapse when pressed (45-60 degrees of resistance)

Most regular shoes fail these tests. Sandals? They increase ulcer risk by 4.3 times. Flip-flops? Even worse. A 2022 study from the University of Michigan found that 67% of patients switch to open shoes in summer, even when temperatures hit 89°F. That’s when pressure spikes and skin breaks down fastest.

If your insurance covers it, get fitted by a certified pedorthist. If it doesn’t, look for shoes labeled “diabetic” with deep toe boxes and removable insoles. Avoid shoes with seams inside, pointed toes, or high heels.

What Doesn’t Work-And Why

There’s a lot of noise out there. Let’s cut through it.

Antibiotics for uninfected ulcers? No. The IDSA’s 2023 guidelines say using antibiotics before an infection sets in doesn’t help healing-and it increases antibiotic resistance by 37%. Don’t take them unless there’s clear infection.

Nerve decompression surgery? No. Nine randomized trials show it doesn’t prevent ulcers. It’s outdated.

Exercise without guidance? Be careful. The IWGDF says foot-ankle exercises are okay for low-to-moderate risk patients-but a 2022 study in Diabetic Medicine found unsupervised ankle exercises increased ulcer risk by 22%. Always get your gait checked first.

Walking 1,000 steps a day? Only if you have no nerve damage and no past ulcers. Dr. David Armstrong, lead author of the 2023 guidelines, says this rule doesn’t apply to most people with diabetes. Too many assume “any movement is good.” It’s not.

Barriers Are Real-But Not Insurmountable

Only 38.7% of doctors in the U.S. do the full annual foot exam. Why? Time, lack of training, no tools. And only 42.1% of patients do daily inspections. Vision problems, severe nerve damage, and low income all make it harder.

If you have trouble seeing your feet, get a mirror. If you can’t afford therapeutic shoes, ask your clinic about programs that provide them. Medicaid now requires annual foot exams in 47 states as of January 2024. You have a right to this care.

Emerging tech like smart socks and AI phone apps can detect temperature changes that predict ulcers 4-7 days before they form. But they cost $150-$300/month. For many, they’re out of reach. That’s why the basics still matter most.

Integrated Care Works

The best outcomes come when care is coordinated. That means your primary doctor, podiatrist, diabetes educator, and orthotist are all on the same page. The CDC’s 2022 Diabetic Foot Care Model showed that integrated care reduced ulcers by 35.7% and amputations by 42.3% in Medicare patients.

If you’re Risk 2 or 3, ask for a care coordinator. Don’t wait for a crisis. Prevention is cheaper, less painful, and far more effective than treatment.

Final Thought: Your Feet Are Your Foundation

You don’t need expensive gadgets or perfect blood sugar to prevent ulcers. You need consistency. You need to look. You need to act. One day of skipping inspection might seem harmless. But ulcers don’t announce themselves. They creep in quietly. By the time you feel pain, it’s too late.

Make your daily foot check part of your morning routine-right after brushing your teeth or before your coffee. Keep the mirror in the same spot. Write down what you see in a notebook. Show it to your doctor every visit. You’re not just checking your feet. You’re protecting your independence, your mobility, and your future.

Preventing diabetic foot ulcers isn’t about perfection. It’s about showing up-for yourself, every single day. One inspection. One pair of proper shoes. One conversation with your doctor. These small acts add up to a life without amputation. Don’t wait for pain. Your feet are telling you something. Listen.