People with diabetes-related foot ulcers can experience severe, unpredictable pain even when nerve damage has dulled sensation in their feet, according to a doctoral thesis from the University of Gothenburg in Sweden. The research, by district nurse Anneli Ringblom, suggests that ulcer pain is often overlooked in routine care, leaving patients to manage it largely on their own.
What the research found
The thesis, Understanding Diabetes-related Foot Ulcers Beyond the Wound: Pain, Patient Experiences and Healthcare Encounters, draws on surveys and interviews with patients living with foot ulcers. Ringblom, of the Institute of Health and Care Sciences at the Sahlgrenska Academy, focused on the patient perspective rather than on specific clinical events.
Patients described pain ranging from a mild, dull ache to a sharp, knife-like sensation on the sole of the foot. Its unpredictability was a major burden. “Patients live with the reality that intense pain can strike suddenly, at any time of day or night,” Ringblom said. The pain disrupted sleep and made it hard to plan daily activities and social life.
Some patients said the pain was so severe that amputation seemed like a way to end the suffering, even though losing a limb is also one of the most feared outcomes of a non-healing ulcer. Others described losing trust in their bodies, having less energy for walking, and carrying a heavy sense of personal responsibility to stop even minor injuries from becoming serious.
A gap in the consultation
In the surveys, patients rated doctors, nurses and foot therapists positively. But they said staff did not always ask about pain, and many held back from raising it themselves to avoid burdening busy clinicians. Ringblom argues that the findings point to a need for greater attention, and clearer strategies, for assessing and relieving pain linked to diabetes-related foot ulcers.
The work is qualitative and based on Swedish patients, and the university’s summary does not give participant numbers. But it challenges a common assumption in diabetic foot care: that a neuropathic foot is a painless foot.
IMEA POD Perspective
The belief that neuropathic ulcers do not hurt is widespread, and it shapes practice across the IMEA region, where clinics are busy and consultations are short. Pain that is not asked about is rarely treated, and unmanaged pain can affect sleep, mood, mobility and willingness to wear offloading devices. It may also push patients towards unproven home remedies or away from follow-up altogether. Podiatrists and wound care nurses are well placed to close this gap. A simple pain question, or a validated pain scale, at every ulcer review costs almost nothing. New or worsening pain in a neuropathic foot should also prompt a check for infection, ischaemia or Charcot changes. Foot teams in the Gulf, India, Pakistan and Africa could add pain assessment to their ulcer protocols and audit how often it is recorded. Listening to patients about pain is also part of building the trust that keeps them coming back for care.
Sources and further reading
- University of Gothenburg: Numbness in diabetic foot ulcers does not rule out pain
- Anneli Ringblom: Understanding Diabetes-related Foot Ulcers Beyond the Wound (doctoral thesis)
- News-Medical: Study highlights overlooked pain from diabetes-related foot ulcers