When Diabetes Affects Your Nerves
Most people know that diabetes affects blood sugar. Fewer realise how profoundly it can affect the nervous system, particularly the nerves that run through the feet and lower legs.
According to Diabetes Australia, up to half of all people with diabetes will develop peripheral neuropathy over time. That's a significant number, and yet it's a complication that often goes unnoticed until something goes wrong. What it does, essentially, is change the way your feet communicate with your brain - and when that communication breaks down, small problems can become big ones without you ever feeling them develop.
At Foot Balance Technology, clinical management of DPN is one of our most common areas of practice. This guide explains what's happening in your feet, what to watch for and what we can do about it.
What Is Diabetic Peripheral Neuropathy?
DPN is nerve damage caused by sustained high blood sugar levels. Over time, elevated glucose damages the structure of peripheral nerves, reducing their ability to carry signals accurately between the feet and the brain. It doesn't happen overnight, and it doesn't always announce itself clearly.
There are three types that affect the feet in different ways.
Sensory neuropathy is the most common. It affects the nerves responsible for feeling - heat, cold, pressure and pain. People with sensory neuropathy may notice tingling, burning or a feeling of walking on cotton wool. Others lose sensation gradually without ever noticing, which is what makes it clinically dangerous.
Motor neuropathy is less talked about but just as significant. It affects the small muscles that give your foot its shape and control how your toes sit. As those muscles weaken, things start to shift - toes begin to claw or curl, the cushioning pad under the ball of the foot moves out of position and pressure starts landing in places the foot wasn't built to handle.
Autonomic neuropathy affects the nerves controlling sweat and oil glands in the skin, leading to dry, cracked skin that is more vulnerable to infection. These three types often occur together, which is why a comprehensive assessment looks at all three rather than any one in isolation.
The Risk Cascade: From Neuropathy to Ulceration
The clinical concern with DPN is not the nerve damage itself but what it allows to happen undetected. A normal foot would send a clear pain signal in response to friction, pressure or heat. A neuropathic foot may send no signal at all.
The way an ulcer develops is worth understanding, because it rarely happens the way people imagine. It is hardly noticeable at first - a pressure point under a bony area of the foot, skin that thickens in response, and then tissue breaking down beneath that thickened skin with every step. By the time a wound becomes visible, it has usually been building for weeks. Patients often say it appeared overnight, but that wasn’t the case at all.
According to the International Working Group on the Diabetic Foot (IWGDF), around 85 per cent of lower limb amputations in people with diabetes are preceded by a foot ulcer. That statistic exists not to alarm but to clarify why early intervention matters and why footwear is a frontline clinical tool, not an afterthought.
Early Warning Signs Worth Taking Seriously
Because DPN often develops gradually, there are early signs worth knowing. Not everyone experiences all of them, and some people experience none until the condition is already well established.
Tingling, burning or numbness in the feet or lower legs - particularly at night - is often the first reported symptom of sensory neuropathy. A feeling of walking on an uneven surface when the ground is flat, sensitivity to touch even from a bedsheet, and changes in the shape of the toes or the arch of the foot can all indicate motor neuropathy is underway. Unusually dry or cracked skin on the feet, regardless of how much moisturiser is used, may point to autonomic neuropathy affecting the sweat glands.
Any of these symptoms in a person with diabetes warrants a conversation with their GP and a specialist foot assessment. They are not inevitable consequences to be managed later. They are early signals that the risk profile of your feet has changed, and your footwear and foot care need to change with it.
Footwear As a Clinical Intervention
Most people think of shoes as a comfort issue. For someone with diabetic neuropathy, the stakes are considerably higher. A shoe that fits poorly, rubs in the wrong place or concentrates pressure under the forefoot can start a chain of events that leads to ulceration - all without the person feeling a thing. That's why we treat footwear as a clinical prescription, not a shopping decision.
A 2022 study protocol in Trials by Dr Ahmed, Paul Butterworth, Alex Barwick, Anita Sharma, MD Zobaer Hasan and Susan Nancarrow further examined how plantar pressure mapping guides bespoke footwear and insole manufacture for high-risk patients. The research reinforces that prescription footwear for neuropathy is a precision process built on objective data, not a general recommendation to "wear sensible shoes."
A 2020 systematic review by Dr Sayed Ahmed, Alex Barwick, Paul Butterworth and Susan Nancarrow, published in the Journal of Foot and Ankle Research, identified the specific design features that reduce neuropathic plantar forefoot ulcer risk. The research makes clear that effective diabetic footwear is defined by measurable clinical characteristics: extra depth and volume to accommodate deformities and insoles, rocker-sole construction to reduce peak forefoot pressure, soft seamless linings to eliminate friction against insensate skin, and adjustable closures to manage swelling and changes in foot shape.
FBT's Clinical Toolkit for Neuropathic Feet
At FBT, every patient with DPN receives a tailored prescription based on their individual assessment findings. The toolkit includes several interventions that work together rather than in isolation.
Medical-grade footwear
Medical-grade footwear is prescribed to address depth, volume, liner quality and closure systems specific to neuropathic risk. Off-the-shelf footwear, even products marketed as diabetic shoes, varies enormously in quality and clinical suitability. A pedorthist prescription ensures the footwear actually matches the foot and the risk profile.
Total contact insoles
Total contact insoles are custom-moulded orthotic devices that distribute plantar pressure across the entire surface of the foot. Rather than allowing pressure to concentrate under the metatarsal heads or heel, a total contact insole creates a uniform load-bearing surface. They are made using 3D scanning and pressure mapping data taken directly from your foot.
Rocker-sole modifications
Rocker-sole modifications reduce peak pressure at the forefoot during the push-off phase of walking. There are four subtypes - heel, toe-only, mid-foot and full rocker - and the subtype prescribed depends on where pressure is concentrated and why. They are applied externally to the sole of prescribed footwear.
Ankle foot orthoses (AFOs)
Ankle foot orthoses (AFOs) are used for more advanced presentations, including Charcot neuroarthropathy, drop foot and significant ankle instability. An AFO controls the position of the foot and ankle during walking and can be fabricated in rigid or dynamic designs depending on the clinical requirement.
The Processes Involved in Our Assessments
"Coming to FBT for a neuropathy assessment isn't like going to a shoe shop, or even a standard podiatry appointment. We're gathering clinical data - sensation testing, blood flow measurement, pressure mapping, 3D scanning - and using all of it together to build a prescription that's specific to your feet and your risk profile.
The process begins with a review of your medical history, diabetes management, current footwear and any previous foot complications. A neurological screening using the 10g monofilament test assesses protective sensation at multiple sites on the sole of your foot. An ankle-brachial index test checks blood flow by comparing blood pressure at the ankle with blood pressure at the arm - a result below 0.9 indicates peripheral arterial disease and changes the clinical picture significantly.
In-shoe plantar pressure mapping identifies exactly where force is concentrated during walking. A 3D foot scan captures the geometry of your foot to inform insole and footwear fabrication. From all of this, a written prescription is produced and fabrication begins in our in-house workshop, under the clinical oversight of Dr Sayed Ahmed - Australia's first PhD in Pedorthics.
Daily Foot Care for People with Neuropathy
Feet with reduced sensation need eyes on them every single day. A quick daily check - both feet, top and bottom, between the toes - is genuinely as important as monitoring your blood sugar. It's the habit that catches problems early, when they're still small enough to manage easily.
Check both feet every day for blisters, cuts, redness, cracks or any change in skin colour. Check inside your shoes before putting them on - a small stone or rough seam that a healthy foot would feel immediately can cause a significant wound on an insensate foot. Never walk barefoot, including indoors. Wash feet in lukewarm water rather than hot, as temperature sensitivity is often reduced. Apply a urea-based moisturiser to the soles and heels but avoid between the toes. Report anything that looks unusual to your GP, podiatrist or FBT promptly rather than waiting to see if it resolves.
When to Talk to Your GP
A GP referral to a pedorthist or podiatrist is appropriate for anyone with diagnosed diabetes, particularly if neuropathy symptoms are present, if foot shape has changed, if there are recurring calluses, or if footwear is causing discomfort or pressure marks. An Enhanced Primary Care plan allows Medicare rebates for up to five allied health visits per year, which can offset the cost of assessment and follow-up.
DVA, NDIS and private health funds may also contribute to the cost of medical-grade footwear and orthotic devices. Our team at FBT can help identify which pathways apply to your situation. Visit our referrals page for more information.
Frequently Asked Questions
DPN is nerve damage caused by sustained high blood sugar. It can affect sensation, muscle control and skin health in the feet. People may experience tingling, numbness or burning, or lose sensation gradually without noticing. Motor neuropathy changes foot shape and pressure distribution, while autonomic neuropathy causes dry, cracked skin.
Common signs include tingling or burning at night, numbness, a feeling of walking on an uneven surface and changes in toe or arch shape. Some people have no symptoms at all. If you have diabetes, a monofilament test at your next clinical appointment will give you a clear picture of where your sensation currently sits.
Without protective sensation, a poorly fitting shoe can cause pressure damage before any pain is felt. Medical-grade footwear with specific design features - depth, rocker soles, seamless linings and custom insoles - reduces peak plantar pressure and removes the mechanical triggers for ulceration.
A total contact insole is a custom-moulded device designed to distribute pressure evenly across the entire sole of the foot, eliminating concentration under vulnerable areas. It is fabricated using 3D scanning and plantar pressure data. A regular orthotic supports the arch but doesn't necessarily address plantar pressure distribution in the same way.
Research consistently shows that appropriately prescribed footwear significantly reduces the risk of neuropathic plantar forefoot ulcers. It does not eliminate risk entirely, particularly where sensation is severely compromised, but it is the single most effective modifiable factor in ulcer prevention for people with DPN.
Charcot neuroarthropathy occurs when neuropathy allows progressive bone and joint damage to develop undetected, sometimes leading to significant foot deformity. Early offloading with a total contact cast is the primary treatment. Once stable, bespoke footwear and AFOs are prescribed to protect the restructured foot and prevent further damage.
The IWGDF recommends assessment every three months for people at Risk Level 2 (neuropathy plus deformity or peripheral arterial disease) and every one to three months for those at Risk Level 3, which includes anyone with a history of ulceration or amputation. Your pedorthist or podiatrist will advise on the right frequency for your situation.
Funding may be available through NDIS under Assistive Technology, DVA for eligible veterans, icare or Enable NSW depending on your circumstances, and private health fund extras. An Enhanced Primary Care plan from your GP covers allied health visits that inform the prescription. Our team can help you identify the right pathway before your first appointment.
Book a Neuropathy Foot Assessment at Foot Balance Technology
If you have diabetes and neuropathy symptoms, or if you haven't had a specialist foot assessment recently, now is the right time to book one. Our certified pedorthists and podiatrists work together to assess your risk, map your foot pressure and prescribe footwear that gives your feet the protection they need.
No referral required. We see patients at our Westmead, Castle Hill and Campbelltown clinics. NDIS, DVA and major health funds are accepted.
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