When Diabetic Foot Ulcers Can Be Managed At Home
Key Insights On Offloading
Most diabetic ulcers result from excessive plantar pressure. If that pressure continues after ulceration, logic suggests that the ulcer is unlikely to heal, no matter what type of topical applications one utilizes. The most effective offloading technique is non-weightbearing on the ulcerated foot. However, compliance with crutches, walkers or wheelchairs is difficult to achieve. Several alternatives to complete non-weightbearing are available, but they represent a compromise and do not fully offload the ulcerated foot. These alternatives include the total contact cast (TCC), removable cast walker and the half shoe.8
The effectiveness of these devices appears to vary inversely with the ease of application. Armstrong and his group studied the effectiveness of these devices and found the TCC promotes healing ulcers in the shortest time (4.3 weeks). This compared to 5.6 weeks for the removable cast walker and 5.5 weeks for the half shoe.8 However, the TCC is difficult and time consuming to apply. There is also a risk of cast induced ulceration with this technique.
Half shoes, other healing shoes and removable cast walkers may be worn over the wound dressing, and should be used with some sort of gait assisting device, such as a cane or walker, to achieve partial weightbearing. If the patient is unsteady or unsure of how to use the offloading devices, home physical therapy for partial weightbearing gait training may be effective. Wheelchairs with leg lifts for the affected extremity allow mobility with effective offloading. One should emphasize making all efforts to facilitate as little weightbearing as possible on the ulcerated extremity.
Heel ulceration is a concern with bedridden patients. One should regularly inspect the heels of both feet and make an effort to cushion or offload the heels while the patient is in bed. Major efforts to accomplish the healing of a midfoot or forefoot ulceration can be totally undone if a patient develops a decubitus ulcer.