Feet, Ulcers and Amputation: Second-Highest in the OECD

Feet, ulcers and amputation: Australia has the second-highest rate in the OECD

Diabetes Feet Australia states two things about this country that should be better known.

Diabetic foot disease is Australia’s leading cause of amputation.

And Australia has the second-highest diabetes-related amputation rate among OECD countries — a position they attribute partly to the lack of coordinated interdisciplinary foot disease services.

The Australian Institute of Health and Welfare recorded 6,300 lower limb amputations in people with type 2 diabetes in 2021–22.

Second-highest in the developed world, in a condition where the pathway to amputation is slow, well understood, and interruptible at four or five separate points. This is not a disease we cannot treat. It is a disease we are not organised to treat.

For people with disability the risk compounds, and the mechanism will be familiar to anybody who has read the pressure injury material on this site. The protective system that normally stops damage is pain. Remove the pain and the damage proceeds silently. Then add the fact that the person may not be able to see their own feet, reach their own feet, or tell anybody that something is wrong — and the first sign is the smell.

We support NDIS participants across New South Wales, including people who need foot checks and skin monitoring as part of daily support. We are not a podiatry or wound service and nothing here is medical advice. Any break in the skin of a person with diabetes needs assessment by an appropriate clinician, quickly.

How a foot gets to amputation

The pathway has three contributing conditions and one accelerant. Understanding the combination explains why prevention works and why delay is so costly.

Peripheral neuropathy — the damage to nerves. High glucose over years damages the small nerves supplying the feet. Sensation to pain, temperature and pressure is lost, usually starting at the toes and moving up in a stocking distribution.

This is the key failure, and it is worth sitting with what it actually means. A stone in the shoe is painless. A new shoe rubbing is painless. A blister is painless. A bath that is too hot causes a burn with no sensation of heat. A seam, a fold in a sock, a nail cut into the skin, a nail left too long pressing the next toe — all painless.

Neuropathy also affects the nerves controlling sweating, so the skin becomes dry and cracks; and the nerves controlling the small muscles of the foot, so the foot deforms — toes claw, the arch changes, and pressure concentrates on a few small points rather than being spread.

Peripheral arterial disease — the damage to blood supply. Narrowed arteries mean less blood reaching the foot. Less blood means less healing and less ability to fight infection. A small wound that would heal in a week on a well-perfused foot can persist for months.

Deformity and pressure — the mechanical trauma. Clawed toes, a prominent metatarsal head, a bunion, a healed previous ulcer, a Charcot deformity, a rigid ankle. Each creates a point where the shoe or the ground loads the skin repeatedly.

And the accelerant: infection. Once the skin breaks, bacteria enter tissue with poor blood supply and impaired immune response. Infection spreads into deeper tissue, then to bone — osteomyelitis — and at that point amputation becomes the likely outcome rather than a possible one.

The sequence in practice: neuropathy means the person does not notice the pressure. Pressure causes callus, then breaks the skin. Poor circulation means it does not heal. Infection enters. Infection reaches bone. The foot, or part of it, is removed.

Every step of that takes weeks. Which is the whole reason daily checking works.

Why disability multiplies the risk

This section is the part most diabetes foot material does not cover, and it is where the preventable harm actually sits.

The person cannot see their feet. Obesity, reduced hip and knee flexibility, a wheelchair, visual impairment, a fused spine. If you cannot physically look at the sole of your own foot, you cannot check it, and the standard advice to inspect your feet daily is useless.

The person cannot reach their feet. So nail care, moisturising and sock changes depend on somebody else.

The person cannot report pain — or cannot report it in a form that gets recorded as a symptom rather than a behaviour. In somebody with communication disability, a painful foot may present as reluctance to walk or transfer, new irritability, withdrawal, or guarding a leg.

Footwear is chosen by somebody else. This is a bigger problem than it sounds. Shoes bought by a family member on sale, or by a worker from a size written on a form, or inherited, or chosen because they are easy to get on. Ill-fitting shoes on a neuropathic foot are the single most common cause of ulceration, and the person cannot tell you they rub.

Orthoses, splints and ankle-foot orthoses create pressure points. Devices prescribed for a completely separate reason — spasticity, foot drop, positioning — sit against skin that cannot feel them. An AFO that fitted last year and does not now will quietly cause an ulcer. Anybody with diabetes wearing an orthosis needs the skin under it checked, every day, and the device reviewed.

Wheelchair footplates. Heels and the backs of ankles against footplates, feet slipping and dragging, toes catching on doorframes, feet knocking during transfers. All painless, all repeated daily.

Transfers scrape feet. Repeatedly, in the same place.

Spasticity causes deformity and pressure, and increased tone can press a foot against a surface continuously.

Oedema from immobility stretches skin, changes shoe fit through the day, and impairs healing.

Continence and moisture macerate skin, particularly between toes.

Somebody else cuts the nails, often with the wrong tools, often cutting into the corner, often not seeing well enough.

Nobody has been told to look. This is the one that converts all of the above into an ulcer. If no one on the roster has a written instruction to check the feet and somewhere to record it, the feet are not being checked.

Daily checking: what and how

Every day. It takes under a minute. Nobody does it reliably unless it is written into the routine.

What to look at:

• The top and sole of each foot
• Between every toe — the most commonly skipped area and a frequent site of fungal infection and maceration
• The heel and the back of the ankle
• Around and under the nails
• Any area under an orthosis, splint, strap or sock elastic
• Anywhere a previous ulcer has healed, because healed ulcer sites re-ulcerate

What to look for:

• Any break in the skin at all — a crack, a graze, a blister, a cut
• Redness, particularly redness that does not fade, and particularly over a bony point
• Warmth compared to the other foot, which is a sign to take seriously
• Swelling
• Callus, especially callus with a dark spot or bleeding underneath, which usually means a wound is forming under it
• A wound of any size — a 3mm hole can be a deep tract
• Discharge, or staining on the sock, which is frequently how an ulcer is first found
• Smell
• Blackened or purple skin
• Ingrown nails, thickened nails, fungal nail or skin infection
• Dry cracked skin, especially at the heel
• Changes in shape, a collapsing arch, or a toe sitting differently
• New reluctance to walk, transfer or be touched on that foot

How to do it where the person cannot:

• A worker during personal care, with an instruction in writing and a place to record it
• A long-handled mirror for people who can look but not reach
• A phone camera — genuinely the best tool available for this, both for seeing the sole and for comparing against last week
• Checking at the same point in the routine every day, usually when socks come off
• Checking inside the shoes as well as on the feet, every time — for stones, folded insoles, rough seams, foreign objects

The rule that saves feet

Any break in the skin on the foot of a person with diabetes is urgent. Not a bandaid matter. Not a wait-and-see matter. Same-day or next-day clinical assessment.

This is the single most important sentence in the guide. A wound on a neuropathic, poorly perfused foot does not behave like a wound on a healthy one. It does not hurt, which means nothing prompts urgency. And it can progress from a small break to a deep infected ulcer in days.

What should happen: the foot is offloaded immediately — weight kept off it — and the person is seen by a GP, a podiatrist with diabetes experience, or a high risk foot service. Not next fortnight when the podiatrist is next due.

Also urgent, and routinely missed: a hot, swollen foot with no wound.

In somebody with neuropathy, a foot that is red, hot and swollen without an obvious wound may be Charcot neuroarthropathy — a condition where the bones and joints of the foot weaken and begin to collapse, usually painlessly or with far less pain than the appearance suggests. It is commonly misdiagnosed as cellulitis, gout or a sprain, and treated with antibiotics or rest while the person keeps walking on it.

Walking on an active Charcot foot destroys it. The bones deform and the arch collapses, producing a shape that cannot be fitted with a shoe and that generates enormous pressure points — which then ulcerate, which then leads to amputation.

The treatment is immediate and complete offloading, usually in a cast or removable walker, for months. Caught early it can be managed. Caught late it is a permanent deformity.

So: a hot swollen foot in a person with diabetes and neuropathy needs assessment urgently, and the words “could this be Charcot?” are worth saying out loud, because it is a diagnosis that gets missed.

Footwear, nails and the things that cause ulcers

Footwear.

• Properly fitted, with room for the toes, no seams pressing, no narrow point
• Fitted on the person, late in the day when feet are at their largest, not bought from a size on a form
• New shoes worn in gradually — an hour, then check the feet
• Shoes checked inside before each wear
• Nothing barefoot, including indoors and including at the beach
• Socks without tight elastic or thick seams, changed daily, and seamless socks where available
• No hot water bottles, heat packs or heaters near the feet — burns on neuropathic feet are common and severe
• Where there is deformity or a previous ulcer, prescribed custom footwear or orthoses, which is a podiatry referral

Nails and skin.

• Nail care by a podiatrist where there is neuropathy, poor circulation, thick or ingrown nails, or where the person cannot do it themselves. This is not a job for a worker with clippers.
• Never cut corns or calluses, and never use over-the-counter corn removal plasters or acid preparations on a diabetic foot. They cause ulcers.
• Moisturise the feet daily, not between the toes, where moisture causes maceration
• Treat fungal infection of skin and nails rather than ignoring it, because it breaks the skin barrier

Getting podiatry funded, and the boundary question

This is a boundary that genuinely confuses people, so here is the distinction as we understand it.

Diabetes-related foot care is health-system funded. Podiatry for diabetic foot disease, foot ulceration, neuropathy assessment and high-risk foot management sits with the health system. Medicare funds a limited number of allied health visits per calendar year for people with chronic conditions under a GP’s chronic condition management arrangements — the relevant items were restructured in 2025, so ask the practice which currently applies. Public high risk foot services exist in many areas and are the right referral where there is active disease.

Disability-related foot care may be an NDIS support. Where somebody needs assistance with routine foot care because of their disability — they cannot reach their feet, cannot see them, cannot hold clippers — the support need arises from the impairment rather than from the diabetes. That is a different proposition from treatment of diabetic foot disease.

In practice the line is blurry and decisions vary. What helps is framing the request precisely: a request for help with foot care because a person cannot physically reach their feet is a disability support request; a request for diabetic foot ulcer management is a health request. Conflating them gets both declined.

And the argument worth making either way: Australia has the second-highest diabetes-related amputation rate in the OECD, the person has a documented high-risk foot, and the cost of regular podiatry is a fraction of the cost of an amputation and the support required afterwards. That comparison is legitimate and it belongs in writing.

What happens after an amputation

Worth stating because it connects to the rest of this library.

Amputation is not the end of the clinical story. Mortality in the years following a major lower limb amputation in people with diabetes is substantial, and the risk to the remaining limb is high — which is why foot care after amputation matters more, not less.

And an amputation is a permanent impairment. The NDIA’s own guidance states that access to the NDIS does not depend on how an impairment arose, and uses amputation as its worked example of a health condition causing disability. Amputation or congenital absence of two limbs is on NDIS List A; a single amputation is assessed on functional capacity, which it frequently meets.

So a person who has lost a foot or a leg to diabetes may have an NDIS access pathway that nobody has mentioned to them. That has its own guide here.

The foot care checklist

• [ ] Daily foot check written into the support routine, with a named responsibility and somewhere to record it
• [ ] Between the toes included
• [ ] Phone camera used where the person or worker cannot see the sole
• [ ] Inside of shoes checked before every wear
• [ ] Footwear professionally fitted, on the foot, late in the day
• [ ] Skin under any orthosis, splint or strap checked daily, and the device reviewed annually or sooner
• [ ] Wheelchair footplates and transfer technique reviewed for foot trauma
• [ ] Nail care by a podiatrist, not a worker
• [ ] No corn plasters, no cutting calluses, no heat sources near feet
• [ ] Annual comprehensive foot examination by a podiatrist or in the annual health assessment, including neuropathy and circulation testing
• [ ] More frequent podiatry where the foot is high risk — previous ulcer, neuropathy, deformity, poor circulation
• [ ] An escalation rule every worker knows: any break in the skin means offload and get it seen today or tomorrow
• [ ] Charcot awareness: hot swollen foot with no wound means urgent assessment
• [ ] Blood glucose management, because it drives all of this
• [ ] Smoking addressed, given the circulation effects
• [ ] A record with dates, so a change is visible against a baseline