Diabetic foot: preventing the complication that costs limbs

Why is the diabetic foot particularly dangerous?

Diabetic foot disease is not simply a slow-healing wound. It is the result of two problems that chronic high blood sugar causes simultaneously: peripheral neuropathy, which reduces or eliminates sensation in the feet, and peripheral arterial disease, which reduces blood flow to the extremities. When both are present, the foot can be injured without the person noticing, and it heals poorly once wounded.

A 2007 study in BMC Family Practice surveyed diabetic patients in the UAE and found that a significant proportion had unrecognised risk factors for foot complications, including impaired sensation and foot deformities. This highlights how often the problem is already developing without the person knowing, which is exactly why routine foot examination is essential.

Amputation rates linked to diabetes are high across the region compared with some other parts of the world. Research from Jordan published in BMC Surgery in 2019 found that a high proportion of major lower-limb amputations at a regional academic hospital were diabetes-related, and many of those cases were potentially avoidable with earlier presentation. This is the reality the routine below is designed to prevent.

Neuropathy: why not feeling pain is so dangerous

Peripheral neuropathy is the gradual damage to the small nerve fibres that carry signals of pain, heat, and pressure from the feet to the brain. It typically starts with numbness, tingling, or a burning sensation in the toes and ball of the foot, and can progress to complete loss of sensation in the affected area.

The danger is that the absence of pain creates a false sense of safety. Someone who cannot feel pain may walk for hours on a sharp stone or a blister, arrive home, and find a deep wound that requires urgent care. That unnoticed moment of injury is the starting point for a series of events that can escalate rapidly if left unattended.

Some signs suggest developing neuropathy before sensation is fully lost: pain in the feet that worsens at night, weakness in the small muscles of the foot causing clawing of the toes, or oversensitivity where even a bed sheet touching the foot at night causes discomfort. Mentioning any of these to your doctor allows early assessment and intervention.

The daily inspection routine: what to look for and how to do it

Daily foot inspection is the single most effective and cost-free preventive tool available. Set aside two minutes every evening after removing shoes. Sit in good light and examine both feet from all angles. If you cannot see the sole directly, use a small mirror placed on the floor, or ask a family member to help.

Look for any change in skin colour, whether redness, unusual pallor, or darkening in any area. Check for swelling in any part of the foot or ankle. Look for wounds, cracks, or fluid-filled blisters, even very small ones. Check the nails for thickening, discolouration, or any sign of ingrowing. Feel for areas of hardened skin (callus) that are increasing in size. Notice any unusual smell from the feet, as odour is sometimes the only sign of a hidden infection in an area the person cannot see directly.

Foot temperature is an important clue. If one foot feels noticeably warmer than the other, this can indicate inflammation developing underneath the skin surface. Comparing both feet is the simplest way to detect this.

Warning signs that cannot wait

Some findings on the diabetic foot require urgent attention that day. Any wound that has not begun to improve within 48 hours needs medical assessment. If a wound is producing discharge or has an unusual smell, these are signs of infection that should not wait for a routine appointment.

Redness spreading from the wound margin out into the surrounding healthy skin, a condition called cellulitis, indicates bacterial spread and is a significant warning sign. It may be accompanied by fever or chills. In this situation, go to the nearest emergency department rather than waiting for a clinic appointment. Hours matter with spreading foot infection.

Darkening or blackening of a toe or area of foot indicates tissue death (gangrene) from absent blood flow. This is an absolute emergency. Any doctor who sees this immediately understands that time is critical. Do not wait to see if it improves.

Choosing footwear in a hot climate

Inappropriate footwear is one of the most common causes of diabetic foot ulcers. Repeated friction from a tight or stiff shoe creates pressure points, and without normal pain signalling, the person does not notice until the friction has caused a wound. A 2005 JAMA review found that appropriate therapeutic footwear significantly reduces recurrence of foot ulcers in diabetic patients.

Choose shoes with a wide toe box that allows the toes to sit without compression. The sole should be thick enough to cushion the foot against ground pressure. The material should allow ventilation, which is especially important in hot climates where moisture inside a shoe adds to skin breakdown risk. Try new shoes in the evening when feet are at their largest, and never buy by size alone without trying them on. Purchasing shoes online without physically fitting them first is a particular risk for a diabetic person.

Never walk barefoot if you have diabetes. Not in the house, not on the beach, not in the garden. Small stones, embers from a barbecue, and the surface temperature of tiles in a Gulf summer are among the most common causes of unnoticed thermal and mechanical injuries. Always wear smooth cotton socks inside shoes, with no seams that press on the toes, and change them daily.

Nail care and managing hard skin

Cut toenails straight across and level with the end of the toe rather than curved at the corners. This prevents the nail edge from digging into the surrounding skin, which causes ingrown toenails and can introduce infection. If nails are very thick or hard, do not attempt to cut them yourself. A podiatrist or trained nurse can do this safely, and in many clinics this is available as part of diabetic foot care.

Callus, the hardened skin that builds up over pressure areas, develops as the foot's protection against friction. The temptation is to use a pumice stone or a blade to remove it at home, but this is genuinely hazardous for a diabetic person. Callus protects the skin underneath, and removing it incorrectly can produce a wound from nothing. Ask your foot care provider to manage it safely on a regular schedule.

Moisturise the feet daily with an unscented cream or lotion applied to the top and sole of the foot. Do not put cream between the toes: excess moisture in that area creates the ideal environment for fungal infection. Athlete's foot (tinea pedis) is common, creates skin breakdown, and opens a route for bacterial infection that can become serious quickly in someone with diabetes.

Nail care tools should be your own and kept clean. Sharing scissors or files with family members risks spreading fungal infection. If you visit a nail salon, inform the technician that you have diabetes and confirm that tools are sterilised between clients. Any small nick or cut from a nail procedure warrants monitoring for the next few days, and any sign of redness or swelling around the nail should prompt a call to your doctor.

Blood sugar and blood pressure control: the deeper prevention

All the foot care routines in the world are supporting work, not a substitute for controlling blood sugar itself. Chronic high glucose accelerates nerve damage and vascular narrowing in the feet. Every 1 percent reduction in HbA1c measurably reduces the long-term risk of foot complications. This is not abstract: it is the difference in years before problems begin.

High blood pressure compounds vascular damage in the feet. If you have both diabetes and hypertension, you are in a category that warrants at minimum two formal foot examinations per year from your doctor. Smoking is another major independent risk factor that deserves direct attention. A patient who smokes, has poorly controlled blood sugar, and does not inspect their feet regularly is combining three compounding risks.

Your doctor should examine your feet at least once a year using a monofilament, a thin plastic thread pressed lightly against the sole that tests whether the protective sensation nerves are still functioning. Pulse checks at the foot complete the vascular picture. If your doctor has not done this recently, ask for it at your next visit. It takes less than two minutes.

When you need a specialist team

A diabetic patient with a foot ulcer needs more than one clinician. Optimal care typically involves the doctor managing the diabetes, a vascular surgeon if blood flow is compromised, a wound specialist, and sometimes physiotherapy for offloading pressure. In major cities across the region, dedicated diabetic foot clinics exist; in smaller towns, ask your general doctor for a referral rather than managing a foot wound alone.

A 2025 protocol review in Epidemiologic Reviews on diabetic foot disease management across the Gulf Cooperation Council found that the region lacks standardised management pathways and that many patients arrive at hospital at advanced stages. This means the patient themselves must be the early warning system, which is precisely what the daily routine in this article is for.

Family members play a meaningful role. Teaching someone at home how to inspect the feet when it is physically difficult for the patient to see them clearly, and briefing them on the warning signs that need immediate action, extends the protective net. This is not about reducing the patient's independence: it is about maximising the chance that problems are caught before they escalate.

If you live far from specialist facilities, discuss with your doctor how to build a written emergency plan: who to call first, how to describe a wound clearly over the phone, and which signs mean going directly to a hospital emergency department without waiting for an appointment. Having this plan agreed in advance, before a problem develops, is part of responsible self-management for anyone who has had diabetes for several years.

Sources

• Singh N, Armstrong DG, Lipsky BA et al: Preventing foot ulcers in patients with diabetes, JAMA, 2005
• Al-Maskari F, El-Sadig M: Prevalence of risk factors for diabetic foot complications, BMC family practice, 2007
• Aljarrah Q, Allouh MZ, Bakkar S et al: Major lower extremity amputation: a contemporary analysis from an academic tertiary referral centre in a developing community, BMC surgery, 2019
• Alessa M, Clifford R, Murray K et al: Diabetic foot disease management in the Gulf Cooperation Council countries: a scoping review protocol, Epidemiologic reviews, 2025
• Hingorani A, LaMuraglia GM, Henke P et al: The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery, Journal of vascular surgery, 2016
• Boulton AJ: Diabetic neuropathy and foot complications, Handbook of clinical neurology, 2014
• World Health Organization: Diabetes and lower limb complications