Although many studies have shown strong associations between certain causal factors and patients with foot ulcers, it is unclear how many of these factors interact. A model that could help identify unique causal pathways and pivotal factors associated with the development of foot ulcers may lead to earlier intervention as well as less frequent and less severe complications. Therefore, the purpose of this study was to identify the responsible causal pathways associated with foot ulcers in persons with diabetes, to determine the frequency of components of the pathway and to identify pivotal events of the pathway. Eighty-seven patients with 103 existing or recently healed ulcers were prospectively evaluated. The data used in the pathway analysis reflected seven variables that have been associated with the development of foot ulcers. The data were interpreted to assess which component causes and pivotal events were responsible for the present ulcer. A cluster analysis was used to confirm findings from the descriptive analysis. Twenty-four pathways were identified. The seven most common unique pathways accounted for 64·1% of the cases. The results of the cluster analysis showed four consistent, dominant clusters: (i) neuropathy, deformity, callus and elevated peak pressure; (ii) peripheral vascular disease; (iii) penetrating trauma and (iv) Ill-fitting shoe gear. These results suggest that there is a finite number of key factors that, if identified and addressed with appropriate intervention strategies, may reduce the risk for the cascade of events towards ulceration and subsequent amputation.