Diabetic foot exam: what happens and what your risk group means
Every adult with diabetes should have a full foot exam at least once a year, and more often if their risk is higher. It looks for loss of feeling, poor blood flow and changes in the foot that raise the chance of an ulcer or amputation. (ADA, 2026)(NICE, 2023)
Why the feet are checked
Diabetes can damage the nerves in the feet, so small injuries may not be felt, and they may heal poorly. (MedlinePlus) Nerve damage that dulls feeling is the single most common cause of foot ulcers. Peripheral artery disease (poor blood flow to the legs), foot deformities, callus, a past ulcer or amputation, smoking, and eye or kidney disease also raise the risk. (ADA, 2026)
What happens during the exam
You take off your shoes and socks so both feet can be examined. (NICE, 2023)(MedlinePlus)
| Part | What happens |
|---|---|
| History | Questions about past ulcers, amputation, Charcot foot, vascular procedures, smoking, eye and kidney disease, and symptoms such as pain, burning, numbness, leg fatigue or cramping when walking. (ADA, 2026) |
| Look at both feet | Shoes, socks and any dressings come off. The skin is checked for damage, callus, ulcers, infection or inflammation, and the feet for deformities such as bunions, hammertoes or prominent bones. (ADA, 2026) (NICE, 2023) |
| Feeling (10 g monofilament) | A 10 g monofilament is used to test protective sensation. In the UK and some other countries the Ipswich touch test, using a fingertip, is preferred. (ADA, 2026) (NICE, 2023) |
| One more nerve test | At least one of pinprick, temperature, ankle reflexes or vibration with a 128 Hz tuning fork. No feeling for the monofilament plus one other abnormal test confirms loss of protective sensation. (ADA, 2026) |
| Pulses and blood flow | The foot pulses (dorsalis pedis and posterior tibial arteries) are felt. Signs of poor blood flow may lead to an ankle-brachial index or other vascular tests, which need careful reading in diabetes because stiff, calcified arteries can make results look falsely high. (ADA, 2026) (NICE, 2023) |
The monofilament test finds more advanced nerve damage, but it does not reliably pick up early nerve damage. (ADA, 2026)
What the result means: risk groups
The exam puts you in a risk group, and the group sets how often your feet are checked again. Two systems are used. The International Working Group on the Diabetic Foot (IWGDF) system is the one the ADA reproduces. (ADA, 2026)(IWGDF, 2023)
| IWGDF category | What it means | Foot exam |
|---|---|---|
| 0, very low | No loss of protective sensation and no peripheral artery disease | Once a year |
| 1, low | Loss of protective sensation or peripheral artery disease | Every 6 to 12 months |
| 2, moderate | Two of: loss of protective sensation, peripheral artery disease, foot deformity | Every 3 to 6 months |
| 3, high | Loss of protective sensation or peripheral artery disease, plus a past foot ulcer, an amputation or kidney failure | Every 1 to 3 months |
Source for the IWGDF table: ADA Table 12.1, adapted from the IWGDF. (ADA, 2026) The IWGDF 2023 guideline itself advises yearly screening at very low risk and more frequent screening at higher risk. (IWGDF, 2023)
In England and Wales, NICE uses four groups. (NICE, 2023)
| NICE group | What it means | Reassessment |
|---|---|---|
| Low risk | No risk factors, except callus alone | Once a year, at the annual diabetes review |
| Moderate risk | Deformity, or neuropathy, or peripheral arterial disease | Frequently, for example every 3 to 6 months |
| High risk | A past ulcer or amputation, kidney replacement therapy (dialysis), neuropathy with peripheral arterial disease, or either of these with callus or deformity | Every 1 to 2 months if there is no immediate concern; every 1 to 2 weeks if there is |
| Active foot problem | An ulcer, infection, severe loss of blood flow (chronic limb-threatening ischaemia), gangrene, a suspected acute Charcot foot, or an unexplained hot, swollen foot with a change in colour, with or without pain | Urgent specialist care, not routine checks |
Source for the NICE table: NICE NG19 recommendations 1.3.6 and 1.3.11. (NICE, 2023) NICE also suggests more frequent checks for people at moderate or high risk who cannot check their own feet. (NICE, 2023)
After a higher-risk result
- ADA: people with loss of feeling or a past ulcer or amputation should have their feet inspected at every visit, and people at moderate to high risk are referred to foot care specialists for regular checks. (ADA, 2026)
- NICE: people at moderate or high risk are referred to a foot protection service, which should see them within 2 to 4 weeks at high risk and within 6 to 8 weeks at moderate risk. (NICE, 2023)
Children and teens
NICE advises basic foot care advice for children under 12 with diabetes, and a foot check as part of the annual assessment for young people aged 12 to 17. (NICE, 2023)
Where they differ:
- The touch test: the ADA accepts the 10 g monofilament or the Ipswich touch test, plus at least one other nerve test, (ADA, 2026) while NICE names the 10 g monofilament as part of the foot sensory exam. (NICE, 2023)
- Risk groups: the IWGDF uses categories 0 to 3 based on loss of feeling, poor blood flow, deformity and past ulcers, (ADA, 2026) while NICE uses low, moderate and high risk plus a separate active foot problem group, and counts callus alone as low risk. (NICE, 2023)
- How often at high risk: every 1 to 3 months under the IWGDF table, (ADA, 2026) and every 1 to 2 months under NICE, or every 1 to 2 weeks if there is an immediate concern. (NICE, 2023)
- Lower risk groups: the IWGDF table sets every 6 to 12 months for one risk factor, (ADA, 2026) while NICE puts one risk factor in its moderate group, checked every 3 to 6 months. (NICE, 2023)
Foot changes to report
Contact your provider right away about any foot problems you have. Do not try to treat these problems yourself. Problems to report include:
- Redness, increased warmth, or swelling
- Sores or cracks
- Tingling or burning feeling
- Pain (MedlinePlus)
The ADA says an open ulcer or unexplained swelling, redness or warmth should be referred urgently to a foot care specialist, (ADA, 2026) and NICE counts an unexplained hot, swollen foot with a change in colour as an active foot problem. (NICE, 2023) Because nerve damage can hide pain and redness, a daily look at both feet matters. (MedlinePlus)
Your doctor decides what your result means for you.
This page does not give footwear, wound care, medicine or treatment advice; your doctor or podiatrist decides those. If you have a flagged result, see after an abnormal screening result for questions to ask.
Questions people ask
How often should someone with diabetes have a foot exam?
At least once a year for every adult with diabetes, and more often for anyone at higher risk. The ADA adds that people with loss of feeling or a past ulcer or amputation should have their feet inspected at every visit. (ADA, 2026) (NICE, 2023) (IWGDF, 2023)
What is the monofilament test?
A test of protective sensation using a 10 g monofilament. Not feeling it, together with one other abnormal nerve test, confirms loss of protective sensation, a risk factor for foot ulcers because minor injuries can go unnoticed. (ADA, 2026)
Does a normal foot exam mean I can skip next year?
No. Both the ADA and NICE advise checking at least once a year, and NICE says to tell people at low risk that they could move to moderate or high risk. (ADA, 2026) (NICE, 2023)
What does a high-risk result mean?
It means a higher chance of a foot ulcer or amputation, usually because of nerve damage or poor blood flow plus a past ulcer, deformity or kidney failure. It leads to more frequent checks and a referral to foot care specialists; your doctor or podiatrist decides what follows. (ADA, 2026) (NICE, 2023)
Should I check my own feet?
The ADA advises teaching everyone with diabetes to check their feet daily by touch or with a mirror. MedlinePlus says to look for dry or cracked skin, blisters, sores, cuts, redness, warmth and hard spots, and to ask someone else to look if you cannot see well. (ADA, 2026) (MedlinePlus)