These experts share their advice for their initial assessment of neuropathic and pressure ulcers as well as effective offloading strategies.
What is your initial assessment and approach to offloading lower extremity neuropathic ulcers?
For patients with diabetes, Kazu Suzuki, DPM, CWS, says one must “put on a detective hat and get to the bottom of the problem.” He recommends that clinicians determine if the patient has a mild degree of neuropathy or is completely insensate and numb with profoundly severe neuropathy.
David G. Armstrong, DPM, MD, PhD, says one must first identify three key points: degree of tissue loss (wound), degree of ischemia and degree of foot infection. He suggests use of the WIfI (wound, ischemia, foot infection) classification system. With the WIfI system, he says one can then label wounds as “none/mild/moderate/severe.” Dr. Armstrong says this allows a mental checklist that can predict a limb threat.
Tammer Elmarsafi, DPM, begins with understanding the etiology of the ulceration. As he says, a chronic venous stasis ulcer on the posterior aspect of the lower leg is different than an acute painful ulcer secondary to a systemic rheumatologic process, such as pyoderma gangrenosum.
Are the shoes flimsy, ill-fitting or otherwise a bad choice of shoe gear? Dr. Suzuki often sees patients with diabetic neuropathy who are wearing shoes that are one size too small or shoes with very tight shoe laces because they have numb feet, and that is the only way they could feel “secure and steady” in their shoes. He points out that ill-fitting shoes may lead to blisters or foot ulcers.
Dr. Suzuki notes having a harder time finding a local prosthetic store that participates in the Medicare Therapeutic Shoe Program. He also says some of his patients also refuse to wear prescription diabetic shoes because they are made of leather and are rather heavy by definition. These days, Dr. Suzuki has been sending his patients with diabetes to a local shoe store that measures foot length and width. He asks patients to be fitted in a pair of well-structured running shoes with a stretchy cloth upper. Dr. Suzuki believes this is better than keeping them in ill-fitting shoes.
What is your offloading device of choice for diabetic neuropathic foot ulcers?
Dr. Suzuki says patient education goes a long way in offloading. He advocates educating patients on minimizing steps and reminding them that each step taken is delaying proper wound healing. Given that the recurrence rate of diabetic foot ulcers (DFUs) is about 40 percent in one year, Dr. Suzuki emphasizes having a long-term game plan to educate and guide patients toward healing and prevention of DFU recurrence.1
Dr. Elmarsafi notes that offloading is secondary to treating the underlying condition, optimizing the general health of the patient and mitigating all risk factors that can contribute to continued progression and/or recurrence. However, he says offloading is still a key component to the ongoing treatment and rehabilitation of the affected tissues. He notes offloading should ideally be comfortable enough for the patient to tolerate; effective at reducing shear and load pressures to the area(s) of concern; and fit properly to prevent additional tissue injury.
As Dr. Elmarsafi explains, all anatomic areas of the foot where an osseous prominence comes in prolonged contact with an unyielding surface are at risk for tissue breakdown in the neuropathic foot. For patients with plantar ulcerations, he says a well-padded total contact cast (TCC) has proven the test of time.
“(The TCC) still remains the workhorse of plantar ulcers as long as the patient is able to follow up on a weekly basis for cast removal, wound reevaluation and reapplication as required,” says Dr. Elmarsafi.
The offloading device of choice depends on factors including the location of the wound, the degree of activity and sometimes what actually caused the wound, notes Dr. Armstrong. That said, he prefers an irremovable offloading device, especially for plantar wounds.
For medial and lateral foot ulcers, Dr. Elmarsafi says a diabetic healing boot “has enough real estate” to effectively relieve pressure to these areas. He also prefers this method for offloading forefoot ulcers over wedge type offloading shoes as the boot offers patients stability and decreases the risk of fall-related injuries.
Dr. Suzuki will also use thick foam dressings such as Allevyn (Smith and Nephew) and RTD Wound Dressings (Keneric Healthcare). While he notes these modalities are not offloading devices per se, they do provide cushioning and shear force reduction to the wound bed. He sometimes adds an abdominal gauze pad and a multilayer compression bandage over the primary dressing to provide an increased cushioning effect.
A standard “surgical sandal” or “fracture healing sandal” can be very effective. Dr. Suzuki says the soles of these sandals do not bend and reduce plantar pressure. He says one could add a piece of felt pad to the sandal or glue it to the insole of the sandal to gain more pressure reduction.
A long-leg controlled ankle motion (CAM) walker boot, notes Dr. Suzuki, is the next step in immobilizing the ankle joint and provide a rocker bottom sole.
“Although I used to prescribe a lot of contact casting when I worked side-by-side with a casting technician, I do not have that luxury now and I believe a well-designed dressing and a CAM walker can provide an equal amount of plantar pressure reduction,” maintains Dr. Suzuki.
If the patient has an obvious bony deformity or protrusion, Dr. Suzuki notes it is wise to recommend bunionectomy or exostectomy to correct those orthopedic deformities as long as the vascular status is acceptable and the patient is a good candidate for elective foot surgery.
“In reality, I will be using all of the aforementioned methods to gain the most effective offloading results possible, given that hospitalization and complete non-weightbearing are often hard to do, and difficult to be accepted by our patients,” says Dr. Suzuki.
Dr. Suzuki will also discuss weight if a patient appears overweight or obese. If patients carry less weight, he believes there will be less stress on their feet. He educates patients that losing weight is as simple as counting calories and emphasizes that exercise is rather secondary. Dr. Suzuki may encourage them to join Weight Watchers, use a dietary app (such as MyFitnessPal) or refer them to a bariatric/nutritionist clinic.
What is your initial assessment and approach to offloading lower extremity pressure ulcers?
Dr. Suzuki suggests interviewing and assessing the overall medical status of each patient as pressure ulcers tend to arise in older and sicker patients than most of the patient population, including typical patients with DFUs. He speculates this may be the case because such patients were acutely ill and immobilized for a prolonged period. For example, he notes a period of hospitalization after fixation of a broken hip followed with a week of complete bed rest.
Dr. Suzuki often sees heel pressure ulcers in patients with Parkinson’s disease. He says these patients tend to be “rigid” and may have difficulty changing their body position in their sleep. Sometimes, he will see pinpoint-shape, smaller ulcers over the lateral malleolus.
How do you offload pressure ulcers?
Dr. Elmarsafi says for pressure ulcers, Prevalon Heel Protectors (Sage Products) or similar soft-pillow heel boots are the gold standard for treating heel or foot/ankle pressure ulcers. However, Dr. Suzuki says one should reserve Prevalon Heel Protectors and other similar offloading devices for patients with excellent blood supply to the heel.
One can recommend the use of soft pillows under the calves to suspend the heel for superficial early-stage pressure ulcers in patients who developed the ulcer secondary to an acute event (ICU admission) that has subsided, according to Dr. Suzuki. However, he notes for patients who are bedridden, the Rooke boots (Osborn Medical) and Multi Podus boots are excellent alternatives. Ideally, Dr. Suzuki says one should offload pressure ulcers of the heel that are complicated with non-reconstructible ischemia via suspension rather than padding.
For the bedridden patient, Dr. Armstrong suggests directing offloading efforts toward comfort, ease of application and direct communication with nursing staff. He says one can then create a customized offloading regimen for that patient.
Dr. Elmarsafi recommends having a soft bed surface, such as a generic memory foam cushion mattress or mattress topper, or a prescription powered, low air-loss mattress for those with multiple severe pressure ulcers. If the patient is underweight or otherwise frail, he recommends a Roho chair cushion (available via Amazon.com or a local medical supply store) as such patients may have a buttock ulcer or be at high risk for developing one.
Dr. Elmarsafi says reviewing and supplementing nutrition is “extremely important” in patients who may be underweight or appear frail. He asks patients or their caregivers about their appetites, and recommends one to two bottles of Ensure Enlive (Abbott Nutrition) to increase the total daily intake of protein and calories. He notes this “makes a huge difference in how fast they may recover from the pressure ulcers.”
Dr. Armstrong is a Professor of Surgery at the Keck School of Medicine at the University of Southern California (USC). He is the Director of the Southwestern Academic Limb Salvage Alliance (SALSA).
Dr. Elmarsafi is a Fellow in Diabetic Limb Salvage within the Department of Plastic Surgery at MedStar Georgetown University Hospital in Washington, DC.
Dr. Suzuki is the Medical Director of the Tower Wound Care Centers at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo. He can be reached at Kazu.Suzuki@cshs.org.
1. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017; 376(24):2367–75.