Transitioning From Open Wound To Final Footwear: Offloading The Diabetic Foot
Given the potential recurrence and complications with diabetic wounds, this author emphasizes the importance of adapting one’s offloading strategy as the wound progresses to healing. Accordingly, he discusses keys to assessing the biomechanical risks of patients with diabetic foot ulcers and offers insights from the literature on effective offloading modalities.
Offloading devices redistribute plantar pressures and reduce the shock and shear forces that contribute to tissue breakdown and interfere with the normal healing process of open plantar ulcers on the diabetic foot.1,2 The timely application of offloading devices to reduce pressure on pedal wounds and alter a patient’s gait to prevent injury or re-injury of the tissues requires the use of several types of devices and footwear during the course of healing.
The concept of “transitional offloading” first surfaced in 2010.3 The term describes the process of applying different offloading devices at different times during the phases of wound healing to prevent injury to the healing plantar surface based on the available data on the efficacy of various devices. It is the clinician’s job not only to heal the wound but also to protect delicate, recently healed tissues from further breakdown during the wound maturation process.
What You Should Know About The ‘6 W’ Approach To Offloading
In 2006, I developed the “6 W” approach to help practitioners better assess biomechanical risk to the foot and choose appropriate offloading interventions from total contact casts to shoes.2 The 6Ws include: who the patient is; what the patient wears; when the patient walks; where the patient walks; why the patient walks; and the “way” the patient walks.
1. Who the patient is. Consider the patient’s intrinsic anatomical and physiological characteristics.
2. What the patient wears. Review the patient’s choice of footwear.
3. When the patient walks. Determine the amount of time or segment of the day spent standing or walking.
4. Where the patient walks. Inquire about the choice of surfaces and activities where the patient walks.
5. Why the patient walks. Consider the adherence and motivation of
6. The “way” the patient walks. Identify the specific gait characteristics of the patient.
This approach includes the intrinsic component of the patient’s inherent biomechanics, the extent of the effects of diabetes on the foot, the degree of neuropathy and the patient’s basic physiologic status. Also included in the assessment are the patient’s specific footwear choices, the temporal issues associated with walking, walking surfaces, the conditions the foot experiences, the motivational issues associated with ambulation and activity, and the specific gait patterns the patient exhibits.
Each of the above variables are part of a grid and get a relative numerical weight to determine the “6W Biomechanical Risk Assessment” score for that patient.3 The higher the relative score, the greater the risk of tissue damage and the more aggressive the approach to offloading must be (see the table “Assessing The Biomechanical Risk Of Patients” at right).