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Options for Off-Loading the Diabetic Foot

Lavery, Lawrence A. DPM, MPH; Baranoski, Sharon MSN, RN, CWOCN, APN, FAAN; Ayello, Elizabeth A. PhD, RN, APRN,BC, CWOCN, FAAN

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Advances in Skin & Wound Care: May 2004 - Volume 17 - Issue 4 - p 181-186

Reduction of pressure and shear forces on the foot may be the single most important—and most neglected—aspect of treating neuropathic ulceration. Off-loading therapy is a key part of the treatment plan for diabetic foot ulcers. The goal is to off-load (reduce) the pressure at the ulcer while keeping the patient ambulatory. 1-3

Calhoun and colleagues 4 have defined off-loading as “any measure to eliminate abnormal pressure points to promote healing or prevent recurrence of diabetic foot ulcers.” Several methods are available to protect the foot from abnormal pressures (Table 1). Off-loading strategies must be tailored to the age, strength, activity, and home environment of the patient. In general, however, more restrictive off-loading approaches will result in less activity and better wound healing.

Table 1
Table 1:

Education is critical to improve adherence to off-loading. The patient must understand that the wound is a result of repetitive pressure, and that every unprotected step is literally tearing the wound apart.


Methods of off-loading the foot include total contact casting (TCC), removable walking boots, healing sandals, half-shoes, and ankle-foot orthoses.

Total contact casting

Considered the gold standard for off-loading the foot, TCC reduces pressure at the ulcer site while allowing the patient to remain ambulatory. 3,4 A skilled clinician is required to apply the molded plaster cast to ensure a proper fit. A TCC is a modification of a traditional fracture cast with minimum cast padding and a covering to protect the toes. The cast is molded to the contour of the foot and leg so that the foot and leg cannot move within the cast (Figure 1). TCCs are generally changed every 1 to 2 weeks, but in patients with edema or other concerns, the cast may need to be replaced more frequently.

Figure 1
Figure 1:

TCC is one of the most effective ways of treating plantar neuropathic foot ulcers described in the medical literature. 3,6 Studies 5-12 have shown that TCC can heal these ulcers in 6 to 8 weeks.The proportion of wounds that heal in descriptive and randomized clinical trials with TCC is consistently much higher than those using topical growth factors, bioengineered tissue, or special dressings. 13-16

One of the main advantages of using a TCC is that it forces the patient to adhere to off-loading. The ulcer is protected with every step the patient takes, around the clock. Using TCC to facilitate wound healing is analogous to using a fracture cast to heal a fracture—in both cases, healing is facilitated by rest and immobilization. TCC reduces the patient’s activity level, 9 decreases stride length and cadence, and significantly reduces pressure at the ulcer site. 3,6 The main disadvantages for patients are the same as their complaints with a fracture cast—the cast is heavy and hot, and makes bathing, walking, and sleeping difficult.

Removable walkers

A number of removable walking boots are available to help protect and heal foot wounds in patients with diabetes, including the DH Pressure Relief Walker, the Conformer Boot, and the AirCast Pneumatic Walker. Removable walking boots offer several advantages over TCCs: They are relatively inexpensive, they have a protective inner sole that can be easily replaced if it shows signs of wear, they do not require special training for correct and safe application, and they can be easily removed to assess and debride the wound. 6,9

The DH Pressure Relief Walker has been shown to be identical to TCCs in pressure reduction at the site of ulcerations on the sole. 6 The disadvantage to these boots is that patients can remove them, so the element of forced adherence that makes the TCC attractive is lost.

Healing sandals and half-shoes

These products are designed to reduce pressure on the forefoot. They are useful for patients who cannot tolerate a TCC or for those who need a transitional device after removal of a TCC while awaiting therapeutic shoes and insoles. The DH Healing Sandal is a convenient product with hook-and-loop closures, a conforming cover for the forefoot, and a patented pressure-reducing insole. Other types of healing sandals require a pressure-reducing insole added in the office.

Half-shoes, such as the OrthoWedge or Darco products, were originally designed to protect the forefoot after elective surgery. The OrthoWedge shoe has a 1½-inch (4-cm) heel wedge at a 10-degree dorsiflexion angle, so that weight is removed from the forefoot area. Studies by Needleman 17 and Lair 18 provide support for its role in postoperative patients following surgery on the forefoot. However, these types of shoes are not well accepted by patients because they are difficult to walk in. They typically cause pain in the contralateral extremity, and patients with postural instability cannot safely use them.

In a randomized clinical trial that compared TCCs with healing sandals and removable cast boots, patients in the healing sandal group used the device during walking significantly less often than subjects in the TCC group. 9,19

Ankle-foot orthoses

Custom-made ankle-foot orthoses can be used for lower-extremity pathology, including Charcot fractures, tendon injuries, and neuropathic ulcers. The Charcot Restraint Orthotic Walker (CROW), for example, was initially described to treat patients with neuropathic fractures. It provides protection to the neuropathic foot and aids in controlling lower-extremity edema. This device looks like a ski boot; it has a rigid polypropylene shell with a rocker bottom sole. 19

The primary drawback to custom-made devices is cost, typically about $1000. If the structure of the foot changes or local edema resolves, the device can no longer be used. Because a number of less expensive, off-the-shelf products are now available to treat neuropathic wounds, custom ankle-foot orthoses are used less frequently. Off-the-shelf devices should be replaced at regular intervals because the materials in the insoles will lose their effectiveness over time. 20


1. Booth J, Young MJ. Differences in the performance of commercially available 10-g monofilaments. Diabetes Care 2000; 23:984-8.
2. Lavery LA, Vela SA, Fleischli JG, Armstrong DG, Lavery DC. Reducing plantar pressure in the neuropathic foot. A comparison of footwear. Diabetes Care 1997;20:1706-10.
3. Lavery LA, Vela SA, Lavery DC, Quebedeaux TL. Total contact casts: pressure reduction at ulcer sites and the effect on the contralateral foot. Arch Phys Med Rehabil 1997;78:1268-71.
4. Calhoun JH, Overgaard KA, Stevens CM, Dowling JP, Mader JT. Diabetic foot ulcers and infections: current concepts. Adv Skin Wound Care 2002;15:31-42.
5. Walker SC, Helm PA, Pullium G. Total contact casting and chronic diabetic neuropathic foot ulcerations: healing rates by wound location. Arch Phys Med Rehabil 1987;68:217-21.
6. Lavery LA, Vela SA, Lavery DC, Quebedeaux TL. Reducing dynamic foot pressures in high-risk diabetic subjects with foot ulcerations. A comparison of treatments. Diabetes Care 1996;19:818-21.
7. Myerson M, Papa J, Eaton K, Wilson K. The total-contact cast for management of neuropathic plantar ulceration of the foot. J Bone Joint Surg Am 1992;74:261-9.
8. Sinacore DR, Mueller MJ, Diamond JE, Blair VP 3rd, Drury D, Rose SJ. Diabetic plantar ulcers treated by total contact casting. A clinical report. Phys Ther 1987;67:1543-9.
9. Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ, Harkless LB. Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care 2001;24:1019-22. Erratum in: Diabetes Care 2001; 24:1509.
10. Mueller MJ, Diamond JE, Sinacore DR, et al. Total contact casting in treatment of diabetic plantar ulcers. Controlled clinical trial. Diabetes Care 1989;12:384-8.
11. Sinacore DR. Total contact casting for diabetic neuropathic ulcers. Phys Ther 1996;76:296-301.
12. Caputo GM, Ulbrecht JS, Cavanagh PR. The total contact cast: a method for treating neuropathic diabetic ulcers. Am Fam Physician 1997;55:605-11, 615-6.
13. Veves A, Falanga V, Armstrong DG, Sabolinski ML. Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care 2001;24:290-5.
14. Veves A, Sheehan P, Pham HT. A randomized, controlled trial of Promogran (a collagen/oxidized regenerated cellulose dressing) vs standard treatment in the management of diabetic foot ulcers. Arch Surg 2002;137:822-7.
15. Gentzkow GD, Iwasaki SD, Hershon KS, et al. Use of dermagraft, a cultured human dermis, to treat diabetic foot ulcers. Diabetes Care 1996;19:350-4.
16. Wieman TJ, Smiell JM, Su Y. Efficacy and safety of a topical gel formulation of recombinant human platelet-derived growth factor-BB (becaplermin) in patients with chronic neuropathic diabetic ulcers. A phase III randomized placebo-controlled double-blind study. Diabetes Care 1998;21:822-7.
17. Needleman RL. Successes and pitfalls in the healing of neuropathic forefoot ulcerations with the IPOS postoperative shoe. Foot Ankle Int 1997; 18:412-7.
18. Lair G. Use of the Ipos Shoe in the Management of Patients with Diabetes Mellitus. Cleveland: Cleveland Clinic Foundation; 1992.
19. Catanzariti AR, Haverstock BD, Grossman JP, Mendicino RW. Off-loading techniques in the treatment of diabetic plantar neuropathic foot ulceration. Adv Wound Care 1999; 12:452-8.
20. Lavery LA, Vela SA, Ashry HR, Lanctot DR, Athanasiou KA. Novel methodology to obtain salient biomechanical characteristics of insole materials. J Am Podiatr Med Assoc 1997;87:266-71.
21. Helm PA, Walker SC, Pullium G. Total contact casting in diabetic patients with neuropathic foot ulcerations. Arch Phys Med Rehabil 1984;65:691-3.
22. Lavery LA, Armstrong DG, Walker SC. Healing rates of diabetic foot ulcers associated with midfoot fracture due to Charcot’s arthropathy. Diabet Med 1997;14:46-9.
23. Knowles EA, Armstrong DG, Hayat SA, Khawaja KI, Malik RA, Boulton AJ. Off-loading diabetic foot wounds using the Scotchcast boot: a retrospective study. Ostomy Wound Manage 2002;48(9):50-3.
24. Chantelau E, Breuer U, Leisch AC, Tanudjaja T, Reuter M. Outpatient treatment of unilateral diabetic foot ulcers with “half-shoes.” Diabet Med 1993;10:267-70.
25. Boninger ML, Leonard JA Jr. Use of bivalved ankle-foot orthoses in neuropathic foot and ankle lesions. J Rehabil Res Dev 1996;33:16-22.
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