Diabetic Foot Ulcers: Risk, Assessment, and the Care Team

Patients with poorly controlled diabetes are at increased risk of developing foot ulcers long before any skin changes are visible. Sensory, motor, and autonomic neuropathy, coupled with impaired circulation and repetitive mechanical pressure, can all contribute. These risk factors often progress silently over the course of years before the first signs of an ulcer become apparent.

Preventing ulceration depends on identifying these risk factors early, performing regular foot examinations, and coordinating care across multiple disciplines.

This guide reviews diabetic foot ulcer risk, the essential components of the foot exam, and the role of the multidisciplinary care team.

Why Diabetic Foot Ulcers Develop

Most diabetic foot ulcers result from three overlapping factors:

• Peripheral sensory neuropathy, which reduces the patient's protective sensation
• Peripheral arterial disease (PAD), which limits blood flow and healing
• Repetitive mechanical pressure, often from deformity or poorly fitting footwear

When these factors occur together, even a minor injury can progress to a chronic ulcer, infection, osteomyelitis, or amputation.

Risk Stratification

Not every person with diabetes has the same risk of ulceration.

The International Working Group on the Diabetic Foot (IWGDF) recommends stratifying patients based on loss of protective sensation (LOPS), peripheral arterial disease, foot deformity, and prior ulceration or amputation.

Risk Category	Typical Findings	Recommended Follow-up*
Very Low	No LOPS, no PAD	Least frequent
Low	LOPS or PAD	More frequent
Moderate	LOPS plus PAD or deformity	Regular surveillance
High	Prior ulcer or amputation with LOPS and/or PAD	Most frequent surveillance

*Follow current IWGDF recommendations and facility protocols.

A patient with a history of ulceration and absent pedal pulses requires much closer monitoring than a patient with newly diagnosed diabetes and intact sensation.

Performing the Diabetic Foot Exam

A comprehensive foot examination should assess four key areas.

Skin and Foot Structure

Inspect pressure points and the spaces between the toes for:

• Calluses
• Fissures
• Color changes
• Skin breakdown

Identify deformities such as claw toes, prominent metatarsal heads, or Charcot changes that increase plantar pressure.

Protective Sensation

Loss of protective sensation is typically assessed with a 10-gram monofilament, often combined with a 128-Hz tuning fork to evaluate vibration perception.

Patients unable to detect monofilament pressure have an increased risk of ulceration.

Perfusion

Assess vascular status by examining:

• Dorsalis pedis pulse
• Posterior tibial pulse
• Skin temperature and texture
• Hair distribution
• Dependent rubor

Absent pulses or signs of ischemia should prompt vascular evaluation.

Footwear and Offloading

Appropriate footwear should be considered part of the treatment itself, rather than an afterthought to it.

Inspect the patient's shoes and inserts directly at each wound care evaluation. Poorly fitting shoes or inadequate offloading can lead to poor outcomes even when the wound care orders are in line with the standard of care.

When an Ulcer Is Present

Assessment extends beyond identifying the wound.

Document:

• Location
• Size and depth
• Infection
• Tissue perfusion
• Offloading strategy

Alongside proper documentation, effective offloading is one of the most important interventions in treating a diabetic foot ulcer.

The Care Team

Successful diabetic foot care requires coordination across multiple disciplines.

Depending on the patient's needs, the care team may include:

• Wound care specialists
• Podiatry
• Vascular specialists
• Primary care or endocrinology
• Nursing staff

An integrated wound care and podiatry model allows clinicians managing wound healing and foot biomechanics to work from a shared treatment plan, reducing delays in care and improving communication.

For skilled nursing facilities, that means specialists who assess the entire foot—not just the wound—and provide a practical plan that nursing staff can implement between visits.

Key Takeaways

• Most diabetic foot ulcers are preventable with early risk identification.
• Neuropathy, peripheral arterial disease, and repetitive pressure are the key risk factors for ulceration.
• Comprehensive foot examinations should include skin, sensation, perfusion, and footwear.
• Offloading is essential to both the prevention of ulceration and the achievement of healing.
• Multidisciplinary care improves coordination and helps reduce complications.