Off-loading the diabetic foot for ulcer prevention and healing

Retrospective and prospective studies have shown that elevated plantar pressure is a causative factor in the development of many plantar ulcers in diabetic patients and that ulceration is often a precursor of lower extremity amputation. In this article, we review the evidence that relieving areas of elevated plantar pressure (off-loading) can prevent and heal plantar ulceration.

There is no consensus in the literature concerning the role of off-loading through footwear in primary or secondary prevention of ulcers. This is likely due to the wide diversity of intervention and control conditions tested, the lack of information about off-loading efficacy of the footwear used, and the absence of a target pressure threshold for off-loading. Uncomplicated plantar ulcers should heal in 6 to 8 weeks with adequate off-loading. The total contact cast and other nonremovable devices are most effective because they eliminate the problem of nonadherence to recommendations for using a removable device. Conventional or standard therapeutic footwear is not effective in ulcer healing. Recent United States and European surveys show a large discrepancy between guidelines and clinical practice in off-loading diabetic foot ulcers. Many clinics continue to use methods that are known to be ineffective or have not been proven effective, while ignoring methods that have been demonstrated to be efficacious.

A number of strategies are proposed to address this situation, notably the adoption and implementation of recently established international guidelines, which are evidence-based and specific, by professional societies in the United States and Europe. Such an approach would change the often poor current expectations for healing diabetic plantar ulcers.