Diabetic Foot Ulcers in Black Adults: Preventing Amputation

A diabetic foot ulcer is an open sore, usually on the sole of the foot or a toe, and it is the event that comes before most leg amputations. Among Medicare patients hospitalized with a diabetic foot ulcer, 21.9% of Black patients had a major leg amputation or died within 30 days, rising to 28.0% for Black patients in rural areas (JAMA Network Open, 2022). The highest-value thing you can do in that hospital room is decline to sign a consent form until someone has measured the blood flow reaching your leg.

Diagnosed diabetes reaches 12.1% of Black adults, the second highest of any group the federal government tracks (NIDDK, 2019 to 2021 data). It damages two things at once in the lower leg: the nerves that would tell you a sore exists, and the arteries that would bring blood to heal it. A 1990 study tracing amputations back through their causes found 84% were preceded by skin ulceration, and that minor trauma, ulceration, and wound-healing failure explained 72% of them (Diabetes Care, 1990). The chain has not changed since.

The outcome is decided in the second half of that chain. Among Black Medicare patients who underwent a major leg amputation, 23.6% had received any revascularization, meaning any attempt to reopen the blocked artery, in the two years beforehand (Journal of Vascular Surgery, 2011). More than three in four reached the operating room with no one having tried to restore the blood supply. Inside the Veterans Health Administration, which removes most insurance barriers, the figure was 25.8% (Health Equity, 2023). Different system, same shortfall.

The testing gap is broad. Across 17,463 Medicare patients undergoing nontraumatic amputation, 68.4% had any arterial test in the two years prior (Circulation: Cardiovascular Quality and Outcomes, 2014). Roughly three in ten lost a limb without one measurement of the circulation feeding it. Among Black Medicare beneficiaries with diabetes in the southeastern diabetes belt, major amputations ran 8.5 per 1,000 in 2006 and 4.8 per 1,000 by 2015 (BMJ Public Health, 2023), and the rate is highest where vascular surgeons and podiatrists are scarcest. If you already know your circulation is poor, read our guide to peripheral artery disease in Black adults.

Most wound teaching is built around erythema, the pink flush of inflamed skin. Melanin hides it. When researchers induced erythema across a range of skin tones and measured it with a colorimeter, they found consistently less visible erythema in dark skin tones and concluded that visual erythema is a problematic indicator (Journal of Tissue Viability, 2024). A clinician trained to look for red skin is running a test that performs worse on you. Use signals that do not depend on color:

• Warmth. One spot noticeably hotter than the same spot on the other foot. The earliest usable sign, and it works on every skin tone.
• Swelling. A puffy toe, a swollen forefoot, or a sock line cutting deeper on one side.
• Firmness or bogginess. Press with a fingertip and compare left to right. Tissue that feels hard, or unusually spongy, is damaged.
• Drainage or odor. Any wet spot, crusting, or stain inside the sock. A foul smell means infection until proven otherwise.
• Color change that is not red. Damage often shows as purple, gray, ashy, or simply darker than the skin beside it.
• Dried blood inside a callus. Federal guidance names this as often the first sign of a wound underneath (NIDDK).

Pain is left off that list on purpose. Neuropathy removes protective sensation, and the ADA notes up to 50% of diabetic peripheral neuropathy is asymptomatic, which is exactly how unnoticed minor trauma becomes an ulcer (Standards of Care in Diabetes, 2026). If your feet have gone numb or dead-feeling, that is the risk factor. See our explainer on numbness and tingling with diabetes.

Same time every night, same light. Sit down, both socks off, and look at the top, the sole, the heel, and between every toe, using an unbreakable mirror on the floor if you cannot bend or see well. The ADA writes this into its self-care recommendations. Then run the backs of your fingers over both feet and compare temperature side to side.

That temperature step is not folk advice. In a 15-month randomized trial of 173 people with a prior foot ulcer, those who measured skin temperature at home twice a day and rested the foot when one site ran hot had an ulceration rate of 4.7%, against 12.2% on standard therapy (Diabetes Care, 2007). An infrared thermometer costs less than a copay.

Separately, the ADA grades an annual comprehensive foot evaluation A, its strongest recommendation. If your last physical did not include someone taking your shoes and socks off, you did not get one.

One sentence to carry into a hospital: "I am not signing until I have had objective blood flow testing and a vascular surgery consult." The joint Global Vascular Guidelines from the Society for Vascular Surgery and its European and world counterparts state that everyone with suspected chronic limb-threatening ischemia should be referred urgently to a vascular specialist, and that objective hemodynamic testing is required (European Journal of Vascular and Endovascular Surgery, 2019). That term means artery disease plus rest pain, gangrene, or an ulcer lasting over two weeks, which is where nearly every amputation candidate sits.

Three tests are worth knowing by name.

• Ankle-brachial index (ABI). Blood pressure at your ankle divided by blood pressure at your arm. Painless, five minutes, a cuff and a handheld Doppler. The ADA recommends screening everyone with diabetes over 50, repeated every 5 years if normal.
• Toe pressure. Ask for this one by name. Years of diabetes stiffen the ankle arteries so they resist the cuff, pushing an ABI to a falsely reassuring number. The ADA states that ABIs are inaccurate in people with diabetes because of noncompressible vessels and that toe systolic pressure is more accurate, with a reading below 30 mmHg suggesting PAD and an inability to heal an ulcer. The global guideline names toe pressure the preferred measure.
• Angiogram. A catheter or CT study that maps the blockages and shows whether a bypass or stent has a target. This is the test that answers whether the leg is salvageable.

Amputation is rarely an emergency measured in hours. Sepsis and spreading gas-forming infection are; a wound that has been there two months is not. That leaves room to ask.

• "Has a vascular surgeon seen this foot, or only the team recommending the amputation?"
• "What is my toe pressure and my ABI, and on what dates?"
• "Has an angiogram been done? If not, why not?"
• "Is there a limb preservation program you can refer me to first?"
• "If we proceed, is a lower-level amputation an option?"

The team matters as much as the test. A systematic review of 33 studies of multidisciplinary limb-preservation teams found 31, or 94%, reported reduced major amputation rates (Journal of Vascular Surgery, 2020). Among 55,409 Medicare patients with diabetic foot ulcers, those who saw at least one relevant specialist had longer event-free survival at every ulcer severity (PLOS ONE, 2023). Pooled five-year mortality after a diabetic foot ulcer is 30.5%, and 56.6% after a major amputation (Journal of Foot and Ankle Research, 2020). Keeping the limb is not a cosmetic preference.

Build the team before you need it. Ask for a standing podiatry referral if you have diabetes plus numbness, a foot deformity, a prior ulcer, a prior amputation, or known artery disease, and ask for an ABI and toe pressure at your next visit if you are over 50 or have had diabetes more than 10 years.

If your concerns about your feet have been brushed off before, that is a reason to change clinicians, not to stop asking. You can find a Black podiatrist, vascular surgeon, or primary care clinician in our directory. Ask one question when you call a new practice: "Do you do in-office ABI or toe pressure testing?" A yes tells you circulation is part of how they think about feet.