Multiple risk factors interplay in the formation of foot ulceration and/or limb amputation in the diabetic patient. This study defines the prevalence of foot pathology, lower extremity complications, and known risk factors for ulceration in a cross-sectional analysis of 92 diabetic patients in a Veterans Affairs Metabolic Clinic. Sixteen percent of patients had a history of lower extremity complications including pedal ulceration and/or amputation, previously requiring 1480 hospital days of care. Sixty-eight percent of patients had structural pathology in the foot, including: 51 percent callus, 32 percent hammertoes, 8 percent bunions, and 1 percent Charcot foot. Thirty-four percent of patients were insensate, while 25 percent had autonomic neuropathy. Twenty-two percent of patients had atherosclerosis obliterans as defined by an ankle brachial index less than 0.9; 13 percent suffered from intermittent claudication. The following pathologies were significantly more prevalent in diabetic patients with a history of ulceration and/or amputation compared to those patients without ulceration or amputation: hammertoe deformity (p less than .0001), abnormal cutaneous pressure sensation (p less than .05), abnormal R-R interval (p less than .05), intermittent claudication (p less than .05), and abnormal ankle brachial index (p less than .05). An important finding was that 41 percent of insensate patients were not aware of their sensory deficit. In addition, two-thirds of the patients with vascular disease had palpable pulses. All patients with diabetes should be entered into a basic foot education program. The high prevalence of lower extremity pathology coupled with the inadequacy of history and physical examination in detecting neuropathy and vascular disease emphasize the need for vigorous screening to determine whether patients are at high risk of ulceration/amputation. These patients should be entered into aggressive prophylactic treatment programs.