A new article published in Diabetes Research and Clinical Practice by Jarl and colleagues dives head first into the ongoing debate about the appropriate weight bearing status for patients undergoing treatment for diabetic foot ulcers (DFUs).1 Of course, conventional wisdom suggests that increased weight bearing leads to excessive plantar pressure (vertical pressure + horizontal shear) at the ulcer site which can delay or, in some cases, prevent wound healing. And, this can especially be true in patients with peripheral neuropathy who lack the “gift of pain,” and may not be able to reliably detect skin or tissue loss. However, little evidence exists regarding the impact of different levels of weight bearing activity on DFU healing in conjunction with a prescribed offloading device.
As part of the study, the authors reviewed six relevant articles taken from two systematic reviews, finding “weak evidence to suggest an inverse relationship between weight-bearing physical activity and plantar ulcer healing while utilizing offloading devices.”1 This is surprising considering how much emphasis is typically placed on reducing weight bearing activity to promote DFU healing. Yet, it doesn’t necessarily account for the potential negative impact on physical and mental health caused by activity restriction.
In addition, the authors propose a framework for further related studies, the Diabetic foot Offloading and Activity framework (DOA), which summarizes the way in which various offloading devices decrease plantar pressure, but affect gait, balance and daily activities.1 For example, a knee-high non-removable device (i.e. total contact cast) features a rigid rocker sole that immobilizes that ankle joint and cannot be removed, yet it impairs gait and balance, thereby contributing to decreased daily step counts. Strictly speaking, from an ulcer healing standpoint, this sounds terrific! However, when taken from a different perspective, this reduction in weight bearing activity can have a negative impact on independence of daily activities, ability to work and muscle weakness, all of which can lead to social isolation and decreased quality of life. Furthermore, considering the fact that many patients at risk for DFUs already live with these gait and balance impairments, going into a non-removable cast could further exacerbate these issues.1
We should strive to better understand the needs of our patients’ physical and mental health while dealing with the challenges of healing DFUs. In my experience, patients prefer an open and honest discussion about what activities should or should not be attempted while dealing with an open wound, as well as realistic expectations and potential consequences for deviating from these recommendations. Who knows, maybe a happier patient makes for a healed one, or at least one who wears their boot more often!
Dr. Isaac is the Director of Research with Foot & Ankle Specialists of the Mid-Atlantic (FASMA). He is a Diplomate of the American Board of Foot and Ankle Surgery.
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1. Jarl G, van Netten JJ, Lazzarini PA, Crews RT, Najafi B, Mueller MJ. Should weight-bearing activity be reduced during healing of plantar diabetic foot ulcers, even when using appropriate offloading devices?. Diabetes Res Clin Pract. 2021;175:108733.