Diabetes-related foot disease

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 23 Sep 2025

Last updated: 16 Oct 2025

Diabetes-related foot disease, including ulcers and infections, is a common complication of diabetes mellitus.

The majority of diabetic foot ulcers are caused by repetitive trauma sustained during activity on a structurally abnormal, insensate foot.

Preventing and/or healing ulcers helps prevent bacterial infection and minimizes risk of limb loss.

Initial evaluation and early management may be by primary care providers; however, there should be a low threshold to refer to an interdisciplinary diabetic foot care clinic or inpatient unit especially if there is any tissue loss, loss of sensation, or signs of peripheral artery disease.

The key principles which form the mainstay of management are wound debridement, wound dressings, pressure offloading, treatment of infection, and treatment of ischemia and restoration of tissue perfusion.

Major amputations (i.e., above the ankle) in ambulatory patients are generally avoided, unless there is extensive infection or gangrene so that reconstruction is either not possible or will not preserve meaningful function in the affected limb.

Definition

The term "diabetes-related foot disease" means disease of the foot in a person with current or previously diagnosed diabetes mellitus, including one or more of the following: peripheral neuropathy, peripheral artery disease, ulcer (i.e., a break in the skin that includes as a minimum the epidermis and part of the dermis), infection (i.e., any soft-tissue or bone infection occurring in the diabetic foot, including osteomyelitis), neuro-osteoarthropathy, gangrene, or amputation.[1][2]

History and exam

Key diagnostic factors

history of diabetes mellitus
presence of risk factors
foot ulcer
foot pain
loss of protective sensation
foot deformity
fever or chills

Full details

Other diagnostic factors

malaise
anorexia
foot erythema
edema of foot, ankle, or calf
absent pedal pulses
fluctuance

Full details

Risk factors

sensory neuropathy
previous history of foot ulcer
previous history of amputation
peripheral artery disease (PAD)
end-stage renal disease (ESRD)
foot deformities
limited foot and/or ankle joint mobility
visual impairment
poor glucose control
Charcot’s neuro-osteoarthropathy
obesity
obstructive sleep apnea (OSA)

Full details

Diagnostic tests

1st tests to order

clinical diagnosis

Full details

Tests to consider

CBC
blood glucose level
CRP
erythrocyte sedimentation rate
renal function
microbiologic culture
x-ray foot
ankle/toe pressures and brachial indices
pedal doppler waveforms with pulse volume recordings (PVR)
duplex ultrasound
catheter digital subtraction angiography (DSA)
CT angiography
MR angiography
MRI foot
CT foot
18F-fluorodeoxyglucose (FDG)-PET/CT
99mTc-exametazime hexa methyl propylene amine oxime (HMPAO)-labeled white blood cell scintigraphy
99mTc-labeled ubiquicidin (UBI) SPECT/CT single photon emission computed tomography (SPECT/CT)

Full details

Emerging tests

serum procalcitonin

Treatment algorithm

ACUTE

at initial presentation

ONGOING

after initial definitive treatment

Contributors

Authors

Neal R. Barshes, MD, MPH, FACS

Assistant Professor

Division of Vascular Surgery and Endovascular Therapy

Michael E. DeBakey Department of Surgery

Baylor College of Medicine

Houston

Disclosures

NRB is an author of several articles cited in this topic.

Joseph L. Mills Sr, MD

Professor and Chief

Division of Vascular Surgery and Endovascular Therapy

Michael E. DeBakey Department of Surgery

Baylor College of Medicine

Houston

Disclosures

JLM has been reimbursed for consulting for AnGes and is an author of several articles cited in this topic.

David G. Armstrong, DPM, MD, PhD

Professor of Surgery and Neurological Surgery

Director of Southwestern Academic Limb Salvage Alliance (SALSA)

Keck School of Medicine of University of Southern California (USC)

Los Angeles

Disclosures

DGA is an author of several articles cited in this topic.

Peer reviewers

Professor Vinod Panchbhavi, MD, FACS

Chief, Division of Foot and Ankle Surgery

Director, Foot and Ankle Fellowship Program

Department of Orthopedic Surgery

The University of Texas

Galveston

Disclosures

VP declares that he has no competing interests.

Robert Hinchliffe, MD, FRCS

Reader and Honorary Consultant Vascular Surgeon

St George's Vascular Institute

London

Disclosures

RH declares that he has no competing interests.

Lee C. Rogers, DPM

Associate Professor of Orthopaedics

University of Texas Health Science Center at San Antonio

San Antonio

Disclosures

LR declares that he has no competing interests.

Judith Spratt, DPM

Highly Specialist Podiatrist

Lancashire Care Foundation NHS Trust

Preston

Disclosures

JS declares that she has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

American Diabetes Association. Standards of care in diabetes - 2025. Diabetes Care. 2025 Jan 1;48(Suppl 1):S1-343.Full text

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 Metab Res Rev. 2024 Mar;40(3):e3657.Full text Abstract

Mills JL Sr, Conte MS, Armstrong DG, et al; Society for Vascular Surgery Lower Extremity Guidelines Committee. The Society for Vascular Surgery lower extremity threatened limb classification system: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg. 2014 Jan;59(1):220-34.Full text Abstract

Senneville É, Albalawi Z, van Asten SA, et al. IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023). Diabetes Metab Res Rev. 2023 Oct 1:e3687.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Venous leg ulcer
- Gout
- Acute Charcot neuro-osteoarthropathy
More Differentials
Guidelines
- ACR appropriateness criteria: suspected osteomyelitis of the foot in patients with diabetes mellitus
- Nutrition interventions in adults with diabetic foot ulcers
More Guidelines
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Diabetes-related foot disease

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Emerging tests

Treatment algorithm

at initial presentation

after initial definitive treatment

Contributors

Authors

Neal R. Barshes, MD, MPH, FACS

Disclosures

Joseph L. Mills Sr, MD

Disclosures

David G. Armstrong, DPM, MD, PhD

Disclosures

Peer reviewers

Professor Vinod Panchbhavi, MD, FACS

Disclosures

Robert Hinchliffe, MD, FRCS

Disclosures

Lee C. Rogers, DPM

Disclosures

Judith Spratt, DPM

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice