What you can’t feel can hurt you: Understanding hidden dangers of diabetic neuropathy

This story is featured in the April 2025 Bexar County Medical Society's San Antonio Medicine magazine

About one in 10 Texans is living with Type 2 diabetes - one of the highest rates of the disease in the United States. In San Antonio, the rate is one in six people and another third of the population is prediabetic, according to the American Diabetes Association.

Type 2 diabetes is a chronic condition in which the body cannot produce enough insulin or use insulin properly and, if left uncontrolled, can lead to high blood sugar, heart disease and kidney failure. Chronically elevated blood glucose, common among diabetics, can damage the nerves of the hands, feet and legs. This damage, called neuropathy, puts people at risk for foot ulcers, infection and potential limb amputation.

What is neuropathy?

Neuropathy can feel like burning or prickling sensations in their hand and feet, pain, cramping, numbness or tingling. For some people, neuropathy feels like bugs crawling on them and others perceive that their feet are freezing cold when they are warm to the touch. Some people feel like they're wearing thick socks and cannot feel the ground even when they're barefoot. About half of patients with diabetes will develop neuropathy that is severe enough to cause sensory loss in the feet.

Because neuropathy causes reduced or absent feeling in the feet, people may not sense a minor cut, blister or callus. A small sore can turn into an open wound and lead to the breakdown of surrounding tissue called an ulcer. Having diabetes also causes the body to heal more slowly, adding to an increased risk of long-term open wounds and infection.

Structural foot deformities like hammer toes, bunions or limited joint motion are also precursors to potential foot ulcers. These factors can contribute to pressure sites that turn into ulcers.

Understanding the risks

A recent study from The University of Texas Health Science Center at San Antonio (UT Health San Antonio) on complications from diabetic foot infections found that nearly half of patients with an infection were likely to experience reinfection, even after successful treatment. Patients with unhealed wounds for three months or longer and patients who had bone infections were most at risk of reinfection. Understanding these risk factors can guide provider care and produce better patient outcomes.

"It's not related to people not having effective treatment of the first infection. It's wound healing. When your wound fails to heal or you develop another wound, the clock starts ticking," said Lawrence A. Lavery, DPM, MPH, diabetic foot complications specialist and professor of orthopaedics at UT Health San Antonio, Joe R. and Teresa Lozano Long School of Medicine 's Division of Podiatry.

Clock starts ticking on unhealed wounds

Along with a higher risk of reinfection, patients with unhealed wounds can experience longer healing time, more foot-related hospital readmission and longer hospital stays. Calling awareness to these risk factors could help stem a cycle of infection, reinfection, amputation, re-amputation, repeat hospitalizations and even early death. These diabetic complications can be emotionally and financially draining for patients and their families.

"You come into the hospital and you're dealing with a limb-threatening, life-threatening infection and it gets resolved. Maybe you don't have surgery, maybe you lose part of your foot. You think you're out of the woods and then you get another event," Lavery said.

Men are twice as likely to experience a diabetic-related amputation, many of whom are working age with families. Lavery said individuals often face the difficult decision of staying home to heal properly or returning to work to provide for their loved ones, risking a longer recovery and a higher chance of reinfection.

Lavery said a priority in diabetic care today is developing tools, strategies and treatments to accelerate wound healing. If a wound heals before it becomes an ulcer, it substantially lowers the risk of infection.

"It's about closing the loop faster. If patients don't develop an ulcer, then the event is over. But once someone has an ulceration, they are at risk of having another ulcer or amputation in the next year. With no preventive treatment, about 60% of these patients will have another ulcer," said Lavery.

Younger adults face diabetic crisis

While some may think diabetes and related complications only happen in older adults, Lavery's study shows otherwise. He found that among diabetic patients experiencing chronic foot infections, the average age was 53. In recent years, diabetic complications have risen sharply among younger adults - a trend that shows no signs of stopping as people are developing obesity, high blood pressure and other comorbidities at earlier ages. With the rising incidence of Type 2 diabetes among younger people, youth doesn't guarantee fewer or less severe diabetic complications.

"It's not as much the chronological age as the physiological age caused by the burden of disease that is making them 'older.' We are getting more and more 30-year-olds in the hospital with foot infections. Usually, people don't get neuropathy until they've had diabetes for a decade. People are getting diabetes younger, and it is increasing the number of people facing limb-threatening infections," Lavery said.

An eye on prevention

To help prevent diabetic foot infections and related complications, UT Health San Antonio has developed a comprehensive program that incorporates education, preventive care and addressing potential health care barriers in specialized prevention clinics. UT Health San Antonio podiatrists hosted a free foot screening clinic in February where they conducted quick, painless exams and provided information.

"Once we get people healed, we really need to spend time and resources on preventive strategies like therapeutics use, insoles education and talking to people about their diet and activity. This is a holistic approach to prevention," Lavery said.

The UT Health San Antonio podiatry team has six recommendations to help avoid foot-related diabetic complications:

1. Maintain blood sugar and avoid smoking - Managing blood sugar helps keep neuropathy at bay and smoking can increase circulation problems, increasing risks.
2. Inspect feet daily - Check for blisters, cuts or calluses to catch problems early. An annual visit with a podiatrist is recommended for people with diabetes.
3. Choose the right footwear and socks - Supportive shoes are recommended, such as athletic shoes with arch support, heel counters and adequate toe box. Cushioned, moisture-wicking socks help reduce friction and prevent blisters.
4. Trim toe nails regularly - Cutting nails straight across helps avoid ingrown toenails and infection.
5. Moisturize skin - Diabetes can cause skin to be drier than normal and dry skin can lead to cracks and cuts. Apply a dermatologist-recommended moisturizer to the skin but avoid applying between the toes to avoid potential fungal infections.
6. Always wear shoes - Wearing protective footwear, even in the house, decreases the risk of foot injuries.

Read the April 2025 San Antonio Medicine magazine here.