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DIABETES SERIES · ARTICLE 9 OF 17

Looking after your feet

The two-minute habit that prevents most diabetic amputations.

Of all the long-term complications of diabetes, the one that does the most damage in South Africa is also the most preventable. Diabetic foot disease — wounds, ulcers, infections, and eventually amputations — is the leading cause of non-traumatic lower-limb amputation in this country. The numbers are heartbreaking, and they are growing.

Here's what almost no one says out loud: most of these amputations come from problems that started as something tiny. A small cut. A blister from a new shoe. A callus that was scratched. A toenail that grew the wrong way. In a person without diabetes, these things heal and you forget about them. In a person with diabetes — especially uncontrolled diabetes — they can become silent infections that destroy tissue before anyone notices.

Two minutes a day of foot care can prevent the vast majority of these stories. This article tells you what to do, what to look for, and when to act. It's one of the most important habits you can build.

Before you read on

This article is for everyone with diabetes — Type 1, Type 2, well-controlled or not. The longer you've had diabetes, the more important the routine becomes. If you have been diagnosed for less than a year, start now. If you have had it for ten years, start now.

Why diabetes attacks the feet

Two things diabetes does to the body come together at the feet, with serious consequences.

1. Nerve damage (neuropathy)

Years of high blood sugar damage the small nerves in the legs and feet. The result is reduced sensation — you may not feel pain, heat, cold, or pressure the way you used to. A stone in your shoe that would have hurt anyone else feels like nothing. A blister forming under your sock goes unnoticed. By the time you do notice — usually a discharge or a smell — significant damage may already have been done.

Some people describe a tingling, burning, or pins-and-needles feeling instead — that's also neuropathy, but a different version. Both increase risk.

2. Poor blood flow (peripheral arterial disease)

Diabetes also damages the larger blood vessels, narrowing them and reducing how much blood reaches the feet. Less blood means less oxygen, fewer nutrients, and far slower healing. A small wound that would close in a week on a healthy person can take months on a diabetic foot — or never close at all.

When loss of sensation and poor blood flow happen together, you have the perfect storm: injuries that aren't noticed, plus a body that can't heal them when they are. This is the path to ulcers, infections, and ultimately amputation.

The good news

Almost every step in this pathway is preventable.

Daily checking catches problems before they grow. Good blood sugar control slows the nerve and blood vessel damage. Proper footwear stops most injuries from happening. Annual clinic checks catch what you miss.

Together, these reduce diabetic amputation risk by 80% or more. That's not a small claim — that's the published consensus from multiple international studies.

The daily two-minute foot check

Once a day, every day, look at your feet. Most people do this best at night before bed — feet are clean, you're already sitting down, you can use good light. Pick a time and make it a habit.

What to look for, top to bottom and underneath:

• Cuts, scratches, or grazes. Any break in the skin.

• Blisters. New ones, or old ones that have grown.

• Redness. Especially in patches that weren't red yesterday.

• Swelling. Anywhere on the foot or ankle.

• Calluses or thickened skin. Yellow or hardened patches — usually under pressure points like the ball of the foot or the heel.

• Corns. Hard, painful spots, usually on the tops of toes.

• Cracks. Especially around the heel.

• Colour changes. Pale, blue, dusky, or unusually dark patches.

• Temperature differences. One foot warmer or colder than the other. Use the back of your hand to compare.

• Smell. A sour or rotting smell can be the first sign of infection.

• Ingrown toenails. Nail growing into the surrounding skin.

• Athlete's foot or fungal infection. White patches, scaling, or peeling between toes.

Can't see the soles of your feet?

Use a mirror on the floor. A simple hand mirror placed on the bathroom floor lets you see the soles clearly while sitting.

Or ask someone in your household to check for you. Take turns if more than one of you has diabetes.

If you can't bend down to check, you can also use your phone's camera — turn it on, hold it under your foot, and look at the screen.

Washing, drying and moisturising

How you wash matters almost as much as whether you check. A few simple rules:

• Wash daily with warm — not hot — water. Test the water with your elbow or wrist if your feet can't feel temperature properly.

• Use a mild soap. Antibacterial soap is fine but unnecessary.

• Dry thoroughly. Especially between the toes. Damp skin between toes is where fungal infections start.

• Moisturise the tops and bottoms, not between the toes. Cracked dry skin is an entry point for infection; soggy skin between toes is too. Aqueous cream or plain glycerin works fine — no fancy products needed.

• Trim toenails straight across, not curved. Curved cuts encourage ingrown nails. File rough edges smooth.

• Don't use sharp instruments on calluses or corns. A pumice stone after a shower is fine. Razors, files that cut, and corn plasters with acid are dangerous — they can create wounds you didn't intend.

Shoes and socks — what to wear, what to avoid

The single biggest source of diabetic foot injuries is ill-fitting shoes. Get this right and you've prevented half the problems.

Choosing shoes

• Buy shoes in the late afternoon — feet are at their biggest. Shoes that fit perfectly at 9 AM may be tight by 5 PM.

• Width matters more than length. A shoe should be wide enough that your toes don't touch the sides. Squashed toes cause blisters and pressure sores.

• The shoe should bend at the ball of the foot, not in the middle. Floppy, unstructured shoes don't support the foot properly.

• Closed shoes with proper soles, not slip-slops, sandals or open shoes. Bare or exposed feet are far more likely to be cut, stubbed, or scraped.

• Avoid pointed toes — they push toes together and cause blisters and ingrown nails.

• Break new shoes in slowly. Wear them an hour at a time at first. Check your feet after each wearing.

Choosing socks

• Cotton or wool, not synthetic. Natural fibres breathe; synthetics trap sweat and grow bacteria.

• Seamless if possible. Big seams can rub and cause blisters in someone who can't feel them forming.

• No tight elastic around the ankle. Tight bands cut off circulation that is already not great.

• Change socks daily, more often if your feet sweat.

• White or light-coloured socks let you see any drainage or blood from a wound you didn't notice.

Before you put a shoe on, look inside

Stones, twigs, paper, a wrinkled sock, a curled-up label — these can all damage a foot that can't feel them.

It takes three seconds. Run your hand inside both shoes before putting them on. Every day. This single habit prevents an enormous number of wounds.

The list of things you must not do

Some habits that seem fine for everyone else become dangerous when you have diabetes. The most important DO NOTs:

• DON'T walk barefoot. Not at home, not at the beach, not at the swimming pool. Wear something — slippers indoors, sandals with a sole outdoors.

• DON'T use hot water bottles, heating pads or radiators on your feet. You may not feel them burning until it's too late. Use socks for warmth instead.

• DON'T put your feet straight into hot water without checking the temperature. Use an elbow or a thermometer (37°C is safe).

• DON'T cut your own corns, calluses, or ingrown toenails if you're unsure. Ask a clinic nurse, a podiatrist, or someone with experience. A small wound from self-treatment can become a big one.

• DON'T use corn-removing chemical pads. The acid in them can damage healthy skin around the corn.

• DON'T smoke. It dramatically worsens the blood flow problem in diabetic feet. Of all the changes a diabetic smoker can make, quitting saves more limbs than anything else.

• DON'T ignore a small problem. A blister, a callus, a scratch — these are normal for everyone else but they are your warning signs. Treat them seriously.

When to see a clinic urgently

Same-day medical attention if you notice any of these:

What you see / feel Why it matters Any open wound that won't heal within a few days Could be the start of an ulcer Red, hot, or swollen patch Sign of infection Pus, drainage, or unusual smell Active infection — needs antibiotics Black or dark patches of skin Tissue death — emergency Sudden pain after years of numbness Often a serious problem signalling itself Fever combined with any foot problem Infection has spread — go to a hospital Cold, pale, or bluish foot Sudden circulation problem — emergency

Public clinics treat diabetic foot wounds free of charge under chronic care. Don't delay because of cost — every day a diabetic ulcer is untreated increases the risk of amputation.

The annual foot examination

Once a year, every year, your feet should be checked by a clinic nurse or doctor. This is part of standard diabetic care in South Africa. If your clinic isn't doing this, ask.

The annual exam covers:

• Skin condition, structure, and circulation

• Sensation testing — usually with a small filament (it looks like a fishing line) pressed against different parts of the foot to check if you can feel it

• Pulse check at the ankle and on top of the foot to assess blood flow

• Reflex testing

• Examination of footwear

• Education on what to look for between exams

If your annual exam finds issues — reduced sensation, poor pulses, deformities — your clinic may refer you to a podiatrist (a foot specialist) for ongoing care.

The bigger picture

Foot care for diabetes is one of those things that feels boring and unnecessary right up until it isn't. Most people who go on to lose a toe, a foot, or a leg will tell you, looking back, that there were warning signs they didn't take seriously, and a daily habit they didn't build.

Two minutes. A mirror. A look. A run of the hand inside the shoe before you put it on. These are not heroic habits. They are small, quiet acts that keep your body whole over years and decades. They make the difference between a diabetes that demands attention but lets you live, and a diabetes that takes pieces of you, one at a time.

The next article in this series turns to sick day rules — how to manage diabetes when you get the flu, a stomach bug, an infection, or have to recover from surgery, because these are exactly the times when blood sugar gets unpredictable and most people don’t know how to respond.

Where to get more help

Diabetes South Africa — diabetessa.org.za · 011 792 9888

Your nearest public clinic — annual foot exams are part of chronic care, free of charge. Ask if you haven't been examined

South African Podiatry Association — podiatryassociation.co.za — find a registered podiatrist near you

Phila Today Diabetes Series — next: sick day rules — managing diabetes when you’re ill

Phila Today · Article 9 of 17 in the Diabetes Series