Podiatric input is still mostly reactive, despite the significant advancements in diabetes care in recent decades. All too frequently, patients are referred to podiatry only after infections or ulcers have already occurred. This reactive approach is expensive in terms of healthcare costs and patient outcomes. Although there is evidence that early podiatric involvement lowers the risk of hospitalizations, amputations, and foot ulcers (Bus et al., 2024), systemic integration of preventive foot care into diabetes pathways is still lacking.
Why the System Remains Reactive
Several systemic factors explain why podiatric care is often delayed until complications arise:
Overwhelmed primary care physicians: With limited consultation time, many clinicians prioritize glycemic control, hypertension, and lipid management. Foot health, though critical, is often relegated to secondary status.
Insurance and reimbursement models: Preventive services such as routine podiatric exams, footwear prescriptions, or biomechanical offloading are underfunded, while surgical interventions and hospitalizations are reimbursed at higher rates. This creates a perverse incentive structure that rewards late stage care.
Clinical software gaps: Electronic health records frequently fail to flag high risk patients for podiatry referral. Neuropathy or vascular insufficiency may be documented but not linked to automated referral pathways.
Cultural undervaluation: Within many health systems, podiatry is perceived as ancillary rather than integral. This perception delays integration into multidisciplinary diabetes teams.
The Clinical Burden of Diabetic Foot Complications
Diabetes frequently results in peripheral neuropathy and peripheral artery disease, which reduce blood flow and protective sensation. These circumstances make it possible for minor wounds to develop into severe infections.
Prevalence and recurrence: Between 19% and 34% of people with diabetes will develop a foot ulcer during their lifetime, and recurrence reaches 65% within three to five years (McDermott et al., 2023).
Mortality and morbidity: Lifetime incidence of lower extremity amputation is approximately 20%, and five year mortality following an incident foot ulcer is between 50% and 70% (McDermott et al., 2023).
These figures highlight the critical need for diabetes care pathways to incorporate preventive foot care.
Evidence for Preventive Foot Care
The International Working Group on the Diabetic Foot has released guidelines that highlight (Bus et al., 2024):
Patients at low risk should be screened annually, while those at higher risk should be screened more frequently.
Routine podiatric examinations to identify pre ulcerative lesions, vascular insufficiency, and neuropathy.
Educating patients on daily self monitoring and the use of therapeutic footwear to reduce ulcer incidence.
Early treatment of any pre ulcerative lesion greatly reduces the risk of infection and amputation.
These actions are simple, cost effective, and supported by clinical evidence.
Historical Siloing of Podiatry
Historically, podiatry has been siloed from endocrinology and internal medicine. Multidisciplinary diabetic limb salvage teams are often activated only once an ulcer reaches Wagner Grade 2 or 3, when infection or deep tissue involvement is already present. At this stage, opportunities for biomechanical offloading or vascular optimization have been missed.
This late activation reflects a systemic undervaluation of podiatric expertise. By embedding podiatry earlier in the care continuum, healthcare systems can intervene before irreversible damage occurs.
The Systemic and Economic Case
Reactive care is costly. Diabetic foot ulcers are among the most resource intensive complications of diabetes, driving extended wound care, repeat inpatient admissions and, at the severe end, amputation. Published US cost estimates vary considerably depending on the costing method applied, which itself tells you something about how poorly this burden is captured. In contrast, a one year prevention program incorporating once daily foot temperature monitoring reported a 52% reduction in all cause hospital admissions during participation (Isaac et al., 2020).
Beyond direct costs, diabetic foot complications reduce workforce participation, increase disability claims, and place long term burdens on caregivers. The economic case for prevention is therefore not only clinical but societal.
Missed Opportunities in Care Pathways
Screening gaps: Many diabetes care pathways emphasize HbA1c monitoring but lack structured foot risk assessments.
Referral delays: Patients with neuropathy or vascular disease may see multiple specialists before podiatry is involved.
Fragmented communication: Endocrinologists, vascular surgeons, and wound care teams often operate in silos, with podiatry engaged only after ulceration.
Embedding podiatry earlier would allow for biomechanical interventions, vascular optimization, and patient education before complications escalate.
Shifting the Paradigm
Diabetes pathways need to transition from reactive to proactive care by:
Including podiatric screening in regular diabetes care procedures.
Teaching primary and specialty care physicians about the systemic benefits of podiatric input.
Rewarding preventive foot care instead of late stage interventions by aligning reimbursement models.
Incorporating podiatry into multidisciplinary teams, ensuring early detection and intervention are routine procedures.
Leveraging electronic health record systems to automatically flag high risk patients for podiatry referral.
In the management of diabetes, preventive foot care is essential for maintaining mobility, lowering mortality, and cutting systemic costs. The evidence is clear: if healthcare systems are to effectively address the increasing burden of diabetes, podiatric input must change from reactive to proactive.
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