Mary Sneed wore pumps to a wake – and nearly lost her big toe. “The shoes had only one-inch heels – but that was too high,” says Sneed, of Washington, D.C. “When I got home, my toe was red and blistered.” Soon, the blister had grown to an ulcer. “I was afraid I would lose the toe.”

It took six months of treatment before the toe finally healed. “If I had known the consequences, I never would have worn pointed dress shoes,” she says.

The dress shoes alone didn’t cause Mary Sneed’s ulcer. Like most people with diabetes who develop ulcers, Sneed has peripheral neuropathy, a disease of the nerves in her feet and legs. Sneed couldn’t feel that her toe was being squeezed. She wore the shoes for hours, enough time for her skin to be damaged and an ulcer to start.

Sneed was lucky, because her toe eventually healed. Others aren’t so lucky. Every year, over 50,000 people with diabetes will have a toe or foot amputated because of ulcers.

There is a good chance that you are at risk. Diabetic peripheral neuropathy affects at least 50 percent of people who have had diabetes more than 25 years. About 8 percent of people with type II diabetes have neuropathy when they are diagnosed with diabetes. (This indicates that type 11 diabetes often goes undiagnosed for years. Every year, many of these people develop foot ulcers.

But it doesn’t have to happen. You can protect your feet and learn to recognize the danger signs of an ulcer.

No Pain? No Good

If you develop peripheral neuropathy, you will gradually lose sensitivity in your feet. A pin prick may feel dull. You could step on a splinter or develop a blister and not feel any pain. You have lost your pain protective mechanism.

Sometimes the loss of the pain protective mechanism is not as obvious. For example, after walking a few blocks, there may be a mild pressure on the bottom of your foot. If you felt it, consciously or subconsciously you would change the way you were walking to keep pressure off that area. But if you can’t feel the pressure, you may keep walking the same way the rest of the day – and end up with a much bigger irritation on your foot.

With neuropathy, you may also lose your withdrawal reflex. With a normal withdrawal response, if you dipped your foot into very hot water, you’d pull out quickly. If you have neuropathy, the water may not feel hot. You might soak your feet and end up with a burn.

How Ulcers Start

When you’ve lost your pain protective mechanism and your withdrawal reflex, the door is open to an ulcer. An ulcer is a sore or hole in the skin (just as a gastric ulcer is a sore in the lining of the stomach).

There are four basic ways that ulcers get started if you have neuropathy in your feet.


Bacteria may get into your skin and release toxins (harmful chemicals). These toxins eat away at your skin.

If you didn’t have neuropathy, you’d feel the infection growing and get treatment. If you don’t get treatment, the infection can eventually lead to an ulcer.

Fortunately, there are other signs besides pain that can alert you to a growing infection. You should check your feet every day for any red areas, swelling, or warm spots. If you have any of these signs, call your doctor. Don’t think: Well, it doesn’t hurt, so it must not be serious.

Big Pressure, Short Time

Ulcers can get started with a distinct injury. For example, you step on a nail and it breaks the skin. You can often prevent this kind of injury by never walking barefoot.

Little Pressure, Long Time

If you press on your skin it turns white because you’re squeezing out the blood. This is called blanching. If you keep this up for several hours, the skin at that point may die because of the lack of nutrition.

If you wear a shoe that’s too tight, the shoe squeezes your skin at certain parts of your foot and causes blanching. If you didn’t have neuropathy, you would feel pain after a while, and you’d take the shoe off. If you don’t feel the pain and keep the shoe on, an ulcer may start.

Bed sores (decubitus ulcers) start the same way. When you lie in one place for a long time, the blood gets squeezed out of a particular area (often the back of the heel). These sores can develop in people without diabetes or neuropathy, for example, in someone who is bedridden and doesn’t have the strength to move. In these cases the ulcers may be painful. A person with neuropathy, on the other hand, may be able to move to keep the pressure off a certain place but doesn’t change position because there is no pain.

Medium Pressure, Again and Again

The fourth cause of ulcers is moderate pressure that is repeated. This is how most ulcers on the bottom of the foot develop.

Ideally, your weight would be distributed along the bottom of your feet. But often, particular areas bear extra weight. For example, you may bear slightly more weight on the ball of your foot behind your big toe. Or you may put more pressure on your heels when you walk.

The extra pressure to these areas is repeated with each step you take. Thus, the stress is repeated thousands of times each day. This occurs in people with neuropathy as well as those without it. This is why corns, blisters, and calluses form.

If you didn’t have neuropathy, you would recognize the repetitive stress either subconsciously or consciously. You’d alter your gait slightly to reduce pressure to that area, or you’d limp. You would probably wear different shoes the next day, or put a pad around the sore area, or seek treatment from your podiatrist.

But if you have neuropathy and can’t feel the extra pressure, you might wear the same shoes and walk the same way for days or weeks. Eventually, your skin breaks down in that one area.

You can often prevent this type of ulcer by wearing special shoe inserts (orthotics) or custom-molded shoes. If you develop one of these ulcers, you may need to keep all pressure off the area until the ulcer heals. You may need to use crutches, a wheel-chair, special casts, or you may need to stay in bed.

Low Flow

Even if you don’t have neuropathy, you may develop a foot ulcer. You may have hardening of the arteries in your legs and feet. If so, the circulation in your feet is poor. You may develop ischemic ulcers, which are ulcers that are caused by a lack of blood flow. These are often quite painful. This is different from the type of ulcer that develops as a result of neuropathy, which is usually painless. You may have neuropathy and hardening of the arteries. If so, you could develop a painless ischemic ulcer.

Prevent, Treat Early

You can prevent serious ulcers. The best way is to prevent an irritation in the first place by pampering your feet.

If an irritation does get started, you need to find it early and seek treatment. Checking your feet twice a day will help you catch problems early.


* If it’s not easy for you to look at the bottoms of your feet, have someone else look, or sit on your bed and hold each foot over a small hand mirror placed on the floor.

* Wash your feet every day with warm water and mild soap.

* Check inside your shoes before putting them on. People often find coins or children’s toys that have fallen inside. If you have neuropathy, you might walk around with a coin in your shoe all day and not notice. That could start an ulcer.

* Use a lotion or cream on your feet (but not between your toes) to keep your skin soft. You don’t have to use anything fancy or expensive. In fact, petroleum jelly or solid vegetable shortening (Crisco) are excellent. The best time to use lotion is right after bathing. Use it more often if your skin is very dry.

* Wear soft, protective shoes that you don’t have to squeeze into. Your shoes should give you good support. A good pair of athletic shoes often works well, Ask your foot doctor about getting insoles if your shoes don’t have enough support on their own.

There are several companies that make shoes with extra depth in the toe box and with larger widths.

Medicare may pay for your therapeutic shoes. Ask your health care provider.

* Wear socks that wick away moisture. Acrylic works well. You may want to get padded socks. You can find these in sporting goods stores. Just make sure your shoes fit with these padded socks.

* You may want to wear two or three different pairs of shoes throughout the day, for example, one in the morning and afternoon and another in the evening. That way, if one of the shoes is rubbing a certain place on your foot, it won’t be rubbing for eight hours straight.

* See your podiatrist regularly. He or she will check the circulation and nerve function of your feet, as well as the condition of the skin of your feet. He or she will also check for spots on your feet that may be prone to irritation, for example, a hammertoe that sticks out. Your foot doctor may recommend shoes, orthotics (inserts), or special treatment to suit your needs. In addition, whenever you see your regular doctor or nurse educator, take off your shoes and socks, so he or she will be reminded to check your feet.


* Don’t use heating pads. They can bum you.

* Never go barefoot.

* Don’t soak your feet, unless prescribed for a specific purpose by your doctor. Soaking can dry out your feet by removing oils from your skin. This could lead to cracking. Don’t wash your feet with alcohol or soak your feet in Epsom salts, unless directed to by your doctor, as these will also dry out your skin.

* Many people with diabetes shouldn’t trim their toenails themselves, particularly if they have peripheral neuropathy or vascular disease. If you do care for your nails yourself, use an emery board or nail file rather than scissors or a curved nail clipper. Trim nails straight across, and don’t trim them too short.

* Never try to cut corns or calluses yourself. See your podiatrist for this.