Offloading the diabetic foot ulcer

Abstract

Ulcers develop on insensate feet due to trauma the patient does not feel, and it makes sense that ulcers cannot heal if mechanical trauma is ongoing.1 Andrew Boulton3 has repeatedly stated that it is not what you put on a diabetic foot ulcer that heals it but rather what you take off it. Ideally then, ulcers must be managed with rest and avoidance of all pressure. However, total non-weight bearing is rarely practical and is difficult to achieve. In the neuropathic foot, the overall aim is to redistribute plantar pressures evenly, thus avoiding areas of high pressure that will prevent or delay healing. In the neuro-ischaemic foot, the aim is to protect the vulnerable margins of the foot.2 Patients usually prefer devices that are light and easy to walk with, but in reality the most effective treatment strategy requires a device that will severely disrupt normal activity for 68 weeks.3 De Block and colleagues found that if a plantar foot ulcer fails to heal by approximately 8 weeks, either it is being ineffectively treated or the patient is not being compliant with the treatment regimen.1 It must always be remembered that heel raisers should be applied to the contralateral limb when using any device that raises the heel of the ulcerated limb to avoid limb length discrepancy that may result in postural insecurity and lower back pain. This article will discuss the variety of offloading options, keeping patient adherence in mind.