Diabetic foot ulcer recurrence: keeping your foot in remission

What remission means

Nerve damage that hides pain, pressure from the shape of the foot or the way you walk, and sometimes reduced blood flow all contribute to diabetic foot ulcers.⁠^[1] New skin doesn’t remove those causes, so experts place a foot with a healed ulcer in the highest risk group, also called remission.⁠^[1]

New ulcers don’t always appear where the old one was. In a study that followed 129 people in remission for up to 34 weeks, almost half of the new wounds (48%) formed on the other foot, and only 17% of earlier ulcers were followed by a new one in the same spot.⁠^[2] Protect both feet, not only the scar.

If a wound is open now, start with diabetic foot ulcer treatment.

Shoes that keep pressure off

The international guideline recommends therapeutic footwear with a demonstrated pressure-relieving effect during walking to help keep an ulcer on the sole from coming back, and advises people at risk not to walk without suitable foot protection.⁠^[3] In pooled trials of 1,587 people, ulcers developed in 13.3% of those given therapeutic footwear, compared with 25.4% with usual care.⁠^[1]

The shoes only work when they’re on. In a trial of 171 people with nerve damage and a recently healed ulcer on the sole, shoes adjusted for better pressure relief didn’t significantly lower recurrence over 18 months overall (38.8% vs 44.2%). But among people who wore them for at least 80% of their steps, recurrence was 25.7% with the improved shoes, compared with 47.8% with standard custom shoes.⁠^[4]

We fit therapeutic shoes and custom inserts and recheck them at your visits, since inserts compress and wear. See offloading boots and protective footwear, and Ozturk Foot & Ankle’s page on diabetic foot care and therapeutic shoes (external site).

Warning signs: daily checks and foot temperature

Guidelines advise people at risk to learn everyday foot self-care and to have any pre-ulcer sign treated.⁠^[3] Check both feet every day, including the soles and between the toes, for redness, a blister, a crack or new callus. Ozturk Foot & Ankle has a simple two-minute daily foot check (external site). If part of your foot turns warm, red or swollen, or a toe turns dusky or purple, call us the same day (see red, hot, swollen foot). If skin turns black, the foot turns cold, pale or blue, or redness spreads with fever, call 911 or go to the emergency department (see dark or discolored toes).

Skin temperature can give an early warning. In a 15-month trial of 173 people with a past foot ulcer, one group also checked six spots on their feet daily with an infrared thermometer and cut back on activity when a spot ran more than 4°F (2.2°C) warmer than the same spot on the other foot. Ulcers developed in 8.5% of that group, compared with 29.3% with standard care and 30.4% with a daily foot check and logbook.⁠^[6]

A 2023 review reported a pooled analysis of five trials with 772 people: ulcers developed in 18.7% of those who checked foot temperature at home and walked less when a hot spot appeared, compared with 30.8% without monitoring.⁠^[1] The prevention guideline suggests considering home temperature checks for people at moderate to high risk.⁠^[3] Ask us whether they make sense for your feet.

Regular examinations and foot care

For people at moderate to high risk, guidelines recommend integrated foot care to help keep ulcers from returning.⁠^[3] For a foot with a healed ulcer, that means screening and professional foot care every 1 to 3 months.⁠^[1]

We set your check-ups by your risk. At each visit we trim callus before it builds into pressure, care for the nails, check the skin, sensation and pulses, and go over your shoes and inserts.

If you’ve had a toe or part of the foot removed, see problems after partial foot amputation.

When surgery helps keep the foot healed

Some ulcers return because the pressure behind them comes from the foot itself: a toe that bends down onto its tip, a metatarsal bone pressing into the ball of the foot, or a stiff ankle and tight calf that push weight onto the forefoot.⁠^[7,5] Shoes and inserts can soften that pressure, but they can’t change the shape that creates it. Surgery can.⁠^[7] The prevention guideline says it should be considered only once non-surgical options, such as shoes, inserts and callus care, have been fully evaluated.⁠^[3]

Surgeons call an operation on a numb foot without an open wound, done to lower the risk of a new ulcer, “prophylactic” (preventive) surgery.⁠^[8] In a review of records from 180 people with diabetes who had foot surgery, new or repeat ulcers, infection and amputation tended to rise with each step from planned operations, to operations on an open wound, to emergency surgery for infection.⁠^[9] Each group was made up of different people, so this can’t prove that early surgery prevents emergencies. Still, if surgery is advised, a closed foot without infection is the lower-risk time for it.⁠^[9]

Dr. Ozturk is a Foot and Ankle Surgeon who is also board certified in wound care (FAPWH), so he looks at a healed foot two ways: what keeps the skin intact, and what surgery could change. Not everyone in remission needs an operation. For the feet that need it, he performs these procedures, matched to the pressure point behind the ulcer.

• Achilles tendon lengthening for an ulcer under the ball of the foot linked to a tight calf. Guidelines suggest considering it when that ulcer doesn’t heal with non-surgical offloading.⁠^[7] In a randomized trial of 64 people with a neuropathic ulcer on the sole and limited ankle motion, the operation was done while the ulcer healed in a total contact cast. Healing was similar with or without it (all 30 ulcers with lengthening, 29 of 33 with the cast alone; the gap was not statistically significant). The benefit came afterward: at seven months, ulcers had returned in 15% with lengthening, compared with 59% with the cast alone.⁠^[5] The Center for Lower Extremity Surgery explains a related calf operation, gastrocnemius recession (external site).
• Flexor tenotomy, a small release of the tendon that curls a flexible smaller toe down onto its tip. Guidelines suggest considering it for a flexible hammertoe with a pre-ulcer sign, and advise it for healing an ulcer on the tip or underside of a smaller toe caused by that deformity.⁠^[3,7] In a review of six studies, all 57 toes treated before an ulcer formed stayed ulcer-free, 97% of toe ulcers healed, recurrence was 6%, and complications were uncommon.⁠^[10]
• Metatarsal head resection, joint arthroplasty or metatarsal osteotomy, which reshape the bones under the ball of the foot or the big-toe joint. Guidelines suggest considering these when an ulcer under the ball of the foot or on the big toe doesn’t heal with non-surgical offloading.⁠^[7] See offloading surgery and exostectomy.

If Charcot foot has collapsed the arch, the plan differs; see Charcot foot.

Limits and risks

Preventive surgery can lower the odds; it doesn’t erase them. Even after Achilles lengthening, some people in the trial developed a new ulcer, and push-off strength weakened at first before returning to its starting level by seven months.⁠^[5] Surgery works alongside shoes, daily checks and visits, never instead of them.

Pressure can also move to a new spot. Achilles lengthening can lead to a new ulcer under the heel, and removing part of a metatarsal bone or releasing a toe tendon can create a new pressure point (a transfer lesion) elsewhere.⁠^[7,3] Achilles lengthening may also make falls and infection more likely, though that evidence is less certain.⁠^[7]

Infection is a risk after any foot operation. In 1,465 consecutive foot and ankle operations by one surgeon, surgical site infections followed 9.5% of operations in people with diabetes and 2.4% in people without. Nerve damage, rather than diabetes itself, was most strongly linked to infection.⁠^[11] With poor circulation, a surgical incision may also fail to heal.⁠^[3] Before a preventive operation, we check your circulation with noninvasive testing at our practice. When blood flow is severely reduced, a vascular evaluation comes first, to decide how urgent the operation is and whether blood flow should be restored before or alongside it.⁠^[8] We arrange that with a vascular specialist; see peripheral artery disease. The prevention guideline suggests not using nerve decompression surgery to prevent foot ulcers.⁠^[3]

Recovery after limb salvage surgery explains the weeks after an operation.

When to seek care

See us within a day or two for any foot wound that isn’t healing, especially if you have diabetes.