Diabetic Foot Risk Score: What Your Annual Foot Exam Result Means
Your annual diabetic foot exam puts you in a risk category from 0 to 3. What each one means, how often your feet should be checked, and the operations that can bring your risk down.
Medically reviewed by Dr. Efe Ozturk · Last reviewed
Published 7 min read
November is American Diabetes Month, and World Diabetes Day is November 14. It is a good time to book the foot exam the ADA recommends at least once a year.[1] Here is what your result means and what can move it.
What is a diabetic foot risk score?
It sorts people with diabetes by their chance of a foot ulcer, an open sore that is slow to heal. Doctors also call it diabetic foot risk classification or risk stratification.
The annual exam looks at four things: your skin, the shape of your foot, your nerves and your circulation, including the pulses in your legs and feet.[1] Two findings drive the score:
- Loss of protective sensation (LOPS). Nerve damage from diabetes (neuropathy) has dulled feeling enough that you might not notice a blister or a stone in your shoe. A monofilament test is one of the checks used to find it.[1] Our sister practice explains peripheral neuropathy (external site) and how it is tested.
- Peripheral artery disease (PAD). Narrowed leg arteries bring less blood to the foot. With diabetes, the usual ankle-brachial index can give a misleading reading, and toe pressures are usually more reliable.[1] See why toe pressures matter with diabetes.
The four diabetic foot risk categories
| Category | What puts you there | How often your feet are checked |
|---|---|---|
| 0: very low | No LOPS and no PAD | Once a year |
| 1: low | LOPS or PAD | Every 6 to 12 months |
| 2: moderate | LOPS and PAD, or either one plus a foot deformity | Every 3 to 6 months |
| 3: high | LOPS or PAD, plus a past foot ulcer, any amputation (toe or larger) or kidney failure | Every 1 to 3 months |
The intervals come from expert opinion, since no study has tested them.[2] A foot deformity means something like a bunion, a hammertoe or a prominent bone in the ball of the foot, which raises pressure under the foot.[1] With nerve loss or poor circulation, kidney failure puts you in the high-risk group even if you have never had an ulcer.[2]
Does the risk category predict ulcers?
Yes. In a Texas study of 213 people followed for about three years, using an early version of this system, ulcers formed in 5.1%, 14.3%, 18.8% and 55.8% of people in groups 0 to 3. Every amputation happened in groups 2 and 3.[3] In a 2026 study of 713 adults at a diabetes center, active ulcers ranged from none in the very low group to 38.5% in the high group.[4]
What does each risk category mean for you?
- Category 0. A yearly exam and good daily habits. The ADA says learning good foot care and doing it yourself is often enough at no or low risk.[1] Ozturk Foot & Ankle has a two-minute daily foot check.
- Category 1. More frequent exams that also look for past ulcers, deformity, stiff joints, callus and pre-ulcer signs such as blisters.[2]
- Category 2. Regular checks with a foot care specialist and shoes with pressure-relieving inserts,[1] plus professional care of callus and pre-ulcer signs.[2]
- Category 3. Your feet should be inspected at every visit, ideally by a team that includes a podiatrist.[1] A healed ulcer is in remission, and keeping it closed is its own plan; see the diabetic foot in remission.
Can surgery lower your diabetic foot risk score?
It can, and this is where a surgeon earns a place on your team. The IWGDF writes that risk usually climbs as diabetes progresses, but it may come down after operations that normalize the foot’s structure or improve blood flow to the leg.[2] In its review, the largest effects on preventing ulcers came from self-management and from surgery.[2]
What the procedures have shown:
- Toe tendon release (flexor tenotomy) for a flexible hammertoe pressing its tip into the ground. In a randomized trial of people with warning signs of a toe ulcer, 1 of 39 who had the release developed an ulcer, against 7 of 40 who didn’t, with no serious adverse events.[5] In a review of six studies, all 57 toes released before an ulcer formed stayed ulcer-free.[6] See flexor tenotomy for toe ulcers.
- Achilles tendon lengthening for a tight calf that overloads the ball of the foot. In a randomized trial of people with a forefoot ulcer and a stiff ankle, ulcers came back within seven months in 15% after lengthening plus a cast, against 59% with the cast alone.[7]
- Removing or reshaping a bony prominence (an exostectomy or a reconstruction) when a bump keeps causing sores. The ADA advises surgical reconstruction by an experienced diabetic foot surgeon for stubborn deformities or repeat ulcers that footwear can’t control.[1]
- Restoring blood flow. If your arteries are narrowed, we refer you to a vascular specialist to evaluate revascularization. Better flow is the other route the IWGDF names for lowering risk.[2]
Dr. Efe Ozturk, a Foot and Ankle Surgeon who is double board certified, including in wound care (FAPWH), performs these foot and tendon procedures. Our practice has on-site X-ray and ultrasound, and an X-ray shows the bone behind a pressure point. See ulcers from foot deformity and offloading surgery.
The guideline asks that preventive surgery follow a full look at non-surgical options,[2] so shoes, inserts and callus care usually come first, and surgery when the deformity keeps winning.
Limits of a risk score
A category guides how closely to watch; it is not a prediction about you. The check-up intervals are expert opinion, the Texas study used an older version of the system, and the 2026 study looked at a single point in time.[2,3,4] The IWGDF left Charcot foot out of its categories, though the ADA counts it as a high-risk foot that needs team care.[2,1] Habits matter too: someone with neuropathy who walks barefoot is likely at much higher risk than a low category suggests.[2] Surgery has trade-offs: a toe tendon release, for example, can shift pressure to a new spot or, if circulation is poor, leave an incision that is slow to heal.[2]
Common questions
What is the IWGDF risk classification?
The international system that groups people with diabetes into foot risk categories 0 to 3, based on nerve loss, circulation, deformity, past ulcers or amputations and kidney failure. The ADA uses it in its 2026 Standards.[1]
How often should a person with diabetes have a foot exam?
At least once a year, and more often as risk rises, down to every 1 to 3 months at category 3.[1]
Can my diabetic foot risk category go down?
Sometimes. Only physical findings set the category, and the IWGDF says it may drop after surgery that corrects foot structure or improves blood flow.[2] A past ulcer or amputation can’t be undone, so with nerve loss or poor circulation it keeps you in category 3. That is why preventing the first ulcer matters.
Is a monofilament test enough to know my risk?
Not on its own. The ADA advises pairing it with at least one other nerve test, such as vibration or pinprick, and notes it can miss early nerve damage.[1]
The bottom line
Your diabetic foot risk score tells you how closely your feet need watching. When a bent toe, a tight calf, a bony bump or poor circulation is pushing your score up, surgery or a referral to restore blood flow can do what shoes alone can’t: change the cause. Ask at your next exam which category you are in, and what could move it down.
Reviewing surgeon
Foot and Ankle Surgeon at Limb Salvage Institute, a specialty practice of Ozturk Foot & Ankle. Dr. Ozturk is double board certified, as a Diplomate of the American Board of Podiatric Medicine (DABPM) and a Fellow of the Academy of Physicians in Wound Healing (FAPWH), and is a Fellow of the American Society of Podiatric Surgeons (FASPS) and the American Society of Podiatric Medicine (FASPM).
References
- 1.American Diabetes Association Professional Practice Committee for Diabetes. 12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes-2026. Diabetes Care. 2026;49(Suppl 1):S261-S276. PubMed 41358886 (external site)
- 2.Bus SA, Sacco ICN, Monteiro-Soares M, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3651. PubMed 37302121 (external site)
- 3.Peters EJ, Lavery LA. Effectiveness of the diabetic foot risk classification system of the International Working Group on the Diabetic Foot. Diabetes Care. 2001;24(8):1442-7. PubMed 11473084 (external site)
- 4.Alenazi FZ, Alslamah T, Alharbi B, et al. Clinical Performance of the IWGDF Risk Stratification System for Diabetic Foot Ulceration: A Gender-Disaggregated Study of 713 Patients. Diabetes Ther. 2026. doi:10.1007/s13300-026-01925-w PubMed 42886425 (external site)
- 5.Askø Andersen J, Rasmussen A, Engberg S, et al. Flexor Tendon Tenotomy Treatment of the Diabetic Foot: A Multicenter Randomized Controlled Trial. Diabetes Care. 2022;45(11):2492-2500. PubMed 36151947 (external site)
- 6.Bonanno DR, Gillies EJ. Flexor Tenotomy Improves Healing and Prevention of Diabetes-Related Toe Ulcers: A Systematic Review. J Foot Ankle Surg. 2017;56(3):600-604. PubMed 28476394 (external site)
- 7.Mueller MJ, Sinacore DR, Hastings MK, et al. Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. J Bone Joint Surg Am. 2003;85(8):1436-45. PubMed 12925622 (external site)
This article is general health information and isn’t a substitute for advice from a clinician who knows your history. Read our medical disclaimer and how we review content.
Learn more about this
Condition
Ulcers from foot deformity
Ulcers that form over bent toes, bunions and prominent bones on a foot with reduced feeling, and how offloading and surgery heal them.
Treatment
Offloading surgery
Operations on the calf, Achilles or toe tendons (and sometimes a metatarsal bone) that take pressure off an ulcer so it heals and is less likely to come back.
Condition
After an ulcer heals
How to keep a healed diabetic foot ulcer from coming back, from protective shoes and daily checks to surgery that reduces the pressure behind it.
Treatment
Exostectomy
Removing the bump of bone under an ulcer that won’t heal, from a collapsed Charcot arch to the ball of the foot: who it suits, results and recovery.
Condition
Foot wounds and kidney disease
Foot ulcers and wounds in people with advanced kidney disease or on dialysis, who face a higher risk and need circulation testing and wound care, with any surgery planned alongside their kidney care.
Keep reading
Limb salvage surgery
Toe-Tip Ulcers and Flexor Tenotomy: A Small Procedure, a Big Benefit
An ulcer on the tip of a bent toe is usually a pressure problem with a small fix. How a flexor tenotomy works, who it suits, what the trials found and the trade-offs.
8 min read
Circulation & healing
Why Ankle Pressures Can Look Normal With Diabetes: Toe Pressures Explained
Calcified leg arteries can make ankle pressures look normal, or even high, when the foot is short of blood. Why toe pressures give a truer picture, and how the numbers shape wound care and surgery.
9 min read
Limb salvage surgery
Achilles Lengthening for Forefoot Ulcers That Keep Coming Back
A tight calf can keep an ulcer under the ball of the foot from healing or staying healed. Who the operation suits, what the trials found and the trade-offs.
9 min read
On the Ozturk Foot & Ankle blog
General foot care and non-surgical basics, from our parent practice.