Expert Insights On Offloading Lower Extremity Wounds

Clinical Editor: Kazu Suzuki, DPM, CWS

Given that offloading is critical to healing wounds in the lower extremity, these panelists discuss assessment techniques for wounds, favored modalities for offloading diabetic neuropathic ulcers and how to document pressure wounds.


What is your initial assessment and approach to offloading lower extremity ulcers?


Kazu Suzuki, DPM, CWS, suggests putting on “an investigator hat” and figuring out exactly when and how the ulcer developed from the pressure. As he notes, the answer may be simple. For example, Dr. Suzuki cites a textbook case of a diabetic pressure ulcer under the metatarsal head along with a periwound callus. He says these are very easy to identify.

   For Nicholas Giovinco, DPM, the initial assessment of a wound for offloading starts with palpating the local anatomy. He looks for bony prominence areas in which mobility is limited and shear stresses are not well accommodated. If this area is supple, Dr. Giovinco would suspect shoe wear as the cause of the ulcer.

   When looking inside of the shoe or boot, Dr. Giovinco looks for edges or areas where excessive wear may be taking place. Many times, this is not obvious but he says it only becomes clear when looking at how the patient walks within the shoe gear. Dr. Giovinco adds that dressings and the gait pattern will have an effect on the shoe’s wear pattern.

   Dr. Giovinco also notes that the shoes patients wear to the office are sometimes not the ones they wear the other six days of the week. If one is dealing with an actual pressure ulcer, he says shoes are frequently not the culprit. More commonly, he notes the wound is secondary to low pressure (i.e. from a bed, a wheelchair or an appliance of some kind) over a prolonged period of time, such as after a more proximal procedure or if the patient is otherwise systemically unwell.

   Similarly, Dr. Suzuki notes lower extremity pressure ulcers in a patient with a spinal cord injury may be difficult to figure out as the patients are often completely insensate and cannot indicate how they injured themselves. He recalls seeing foot ulcers that came from the wheelchair foot plate as well as from the side frames and various hardware attached to the chairs.

   For neuropathic diabetic foot ulcers, Desmond Bell, DPM, CWS, will first assess the patient’s structural deformities and then analyze his or her gait. He notes one must determine if the structural deformity of the foot is causing the issues with gait that have led to ulceration, or if there are issues with gait that have manifested with the formation of the ulcer. As Dr. Bell advises, gait and location of the ulcer are “critical” in determining what type of offloading one can utilize.

   In addition, Dr. Bell says one should consider whether a structural deformity is the major factor in the ulcer formation. Will its presence result in re-ulceration of the foot at a later date, assuming that the ulcer can heal in the first place? He stresses that appropriate surgical intervention may be the best offloading method to implement when recurrence is a strong concern.


Do you have any tips or advice on documenting pressure ulcers?


Drs. Bell and Suzuki suggest a starting point of utilizing the classification of the National Pressure Ulcer Advisory Panel (NPUAP). Dr. Bell notes that the NPUAP says pressure ulcer documentation should be “complete, accurate and legally defensible.”1 After determining that an ulcer is a result of pressure, he says one should utilize the NPUAP staging system based on the extent of tissue damage or loss (Stage I-IV).

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