A Guide To Preventative Offloading Of Diabetic Foot Ulcers

Jason R. Hanft, DPM, Daniel T. Hall IV, DPM, and Ashish Kapila, DPM

   Other clinical methods to monitor and improve patient adherence have emerged. One approach is using activity monitors that one can attach to offloading devices.16 This not only allows the physician to track how often patients are using the offloading device but may also encourage better patient adherence with them knowing they are being monitored. However, the practicality of implementing these devices in private practice may be the biggest shortcoming of this technique.

Pertinent Pointers On Preventing Recurrent Ulcers

The ultimate goals in the treatment of the diabetic foot ulcers are salvaging the affected limb, rapid complete wound closure and maintenance of the protective skin envelope. Once wound closure has occurred, the often difficult and frustrating task of preventing recurrent ulceration should begin immediately. Studies suggest that 34 percent of patients will develop a recurrent or new pedal ulceration within one year of healing a wound. Greater than 50 percent of patients will develop a recurrent or new pedal ulcer within three years of healing.17 These findings strongly indicate that lifelong diabetic foot care is required for patients with a known history of diabetic foot ulcers.

   How do we minimize the odds of patients developing new or recurrent pedal ulcers when evidence-based medicine reveals over 50 percent will relapse within a three-year period?17

   We are beginning to understand that preventing recurrent ulcers is proving to be just as challenging as wound healing itself. Much like wound healing, the prevention of diabetic foot ulcers requires one to decrease the strain rate and control the environment in which the foot bears weight.

   In order to properly protect and control the forces about the foot, we must continue to offload and decrease the strain rate once the wound has healed. Selecting an offloading device requires a crucial understanding of the patient’s needs as well as identifying potential risks that may lead to the failure of the device and recurrent ulceration. Patient foot type and/or deformity (i.e. amputation), the location of healed diabetic foot ulcer and potential pressure areas are among the most important factors to consider.

What You Should Know About Shoes And Insoles

Patients with healed ulcers, no amputations or significant pedal deficiencies can transition to a shoe-based total contact device such as a custom-molded shoe with an insole. This can protect the skin surrounding the healed ulcer. The patient can transition into a custom-molded shoe after the tissue and healed ulcer are strong enough to bear the pressure and shear forces of weightbearing. Pressure is spread out across the plantar surface of the foot with total contact insoles so not all the pressure focuses on the previous ulceration site.

   There are various offloading modalities that have insoles with removable diamond or hexagonal shaped pieces to selectively offload particular areas of the foot.18 Patients with digital amputations or partial ray amputations can use custom toe filler insoles in conjunction with custom shoes. However, toe fillers are not indicated in the dysvascular patient because they increase the risk of tissue breakdown.19


I am still amazed how often people talk about compliance with the use of these offloading devices but never mention the severity of leg length discrepancy they cause. A shoe build up makes walking so much easier. Try adding 2 cm to the sole of the shoe on the non-affected side. Then maybe you will be amazed how compliance improves.

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