• 1

    van der Leeden M, Steultjens MP, Terwee CB, et al: A systematic review of instruments measuring foot function, foot pain, and foot-related disability in patients with rheumatoid arthritis. .Arthritis Rheum 59::1257. ,2008. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Sosenko JM: The prevalence of diabetic neuropathy according to ethnicity. .Curr Diab Rep 9::435. ,2009. .

  • 3

    Armstrong DG: Loss of protective sensation: a practical evidence-based definition. .J Foot Ankle Surg 38::79. ,1999. .

  • 4

    Wu SC, Crews RT, Armstrong DG: The pivotal role of off-loading in the management of neuropathic foot ulceration. .Curr Diab Rep 5::423. ,2005. .

  • 5

    Bauman JH, Girling JP, Brand PW: Plantar pressures and trophic ulceration: an evaluation of footwear. .J Bone Joint Surg Br 45::652. ,1963. .

  • 6

    Veves A, Murray HJ, Young MJ, et al: The risk of foot ulceration in diabetic patients with high foot pressure: a prospective study. .Diabetologia 35::660. ,1992. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Pham H, Armstrong DA, Harvey C, et al: Screening techniques to identify people at high risk for diabetic foot ulceration. .Diabetes Care 23::606. ,2000. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Frykberg RG, Lavery LA, Pham H, et al: Role of neuropathy and high foot pressures in diabetic foot ulceration. .Diabetes Care 21::1714. ,1998. .

  • 9

    Pecoraro RE, Reiber GE, Burgess EM: Pathways to diabetic limb amputation: basis for prevention. .Diabetes Care 13::513. ,1990. .

  • 10

    Bus SA: Foot structure and footwear prescription in diabetes mellitus. .Diabetes Metab Res Rev 24: (suppl 1):S90. ,2008. .

  • 11

    Bus SA, Maas M, Cavanagh PR, et al: Plantar fat-pad displacement in neuropathic diabetic patients with toe deformity: a magnetic resonance imaging study. .Diabetes Care 27::2376. ,2004. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    van der Ven A, Chapman CB, Bowker JH: Charcot neuroarthropathy of the foot and ankle. .J Am Acad Orthop Surg 17::562. ,2009. .

  • 13

    Bus SA, Maas M, de Lange A, et al: Elevated plantar pressures in neuropathic diabetic patients with claw/hammer toe deformity. .J Biomech 38::1918. ,2005. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Armstrong DG, Lavery LA: Elevated peak plantar pressures in patients who have Charcot arthropathy. .J Bone Joint Surg Am 80::365. ,1998. .

  • 15

    Pound N, Chipchase S, Treece K, et al: Ulcer-free survival following management of foot ulcers in diabetes. .Diabet Med 22::1306. ,2005. .

  • 16

    Lavery LA, Vela SA, Fleischli JG, et al: Reducing plantar pressure in the neuropathic foot: a comparison of footwear. .Diabetes Care 20::1706. ,1997. .

  • 17

    Fleischli JG, Lavery LA, Vela SA, et al: 1997 William J. Stickel Bronze Award: comparison of strategies for reducing pressure at the site of neuropathic ulcers. .JAPMA 87::466. ,1997. .

    • Search Google Scholar
    • Export Citation
  • 18

    Beuker BJ, van Deursen RW, Price P, et al: Plantar pressure in off-loading devices used in diabetic ulcer treatment. .Wound Repair Regen 13::537. ,2005. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Nagel A, Rosenbaum D: Vacuum cushioned removable cast walkers reduce foot loading in patients with diabetes mellitus. .Gait Posture 30::11. ,2009. .

  • 20

    Shaw JE, Hsi WL, Ulbrecht JS, et al: The mechanism of plantar unloading in total contact casts: implications for design and clinical use. .Foot Ankle Int 18::809. ,1997. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Bus SA, Waaijman R, Arts M, et al: The efficacy of a removable vacuum-cushioned cast replacement system in reducing plantar forefoot pressures in diabetic patients. .Clin Biomech (Bristol, Avon) 24::459. ,2009. .

    • Search Google Scholar
    • Export Citation
  • 22

    Bus SA, van Deursen RW, Kanade RV, et al: Plantar pressure relief in the diabetic foot using forefoot off-loading shoes. .Gait Posture 29::618. ,2009. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Bus SA, Ulbrecht JS, Cavanagh PR: Pressure relief and load redistribution by custom-made insoles in diabetic patients with neuropathy and foot deformity. .Clin Biomech 19::629. ,2004. .

    • Search Google Scholar
    • Export Citation
  • 24

    Guldemond NA, Leffers P, Schaper NC, et al: The effects of insole configurations on forefoot plantar pressure and walking convenience in diabetic patients with neuropathic feet. .Clin Biomech 22::81. ,2007. .

    • Search Google Scholar
    • Export Citation
  • 25

    Praet SF, Louwerens JW: The influence of shoe design on plantar pressures in neuropathic feet. .Diabetes Care 26::441. ,2003. .

  • 26

    van Schie C, Ulbrecht JS, Becker MB, et al: Design criteria for rigid rocker shoes. .Foot Ankle Int 21::833. ,2000. .

  • 27

    Schaff PS, Cavanagh PR: Shoes for the insensitive foot: the effect of a “rocker bottom” shoe modification on plantar pressure distribution. .Foot Ankle 11::129. ,1990. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Lord M, Hosein R: Pressure redistribution by molded inserts in diabetic footwear: a pilot study. .J Rehabil Res Dev 31::214. ,1994. .

  • 29

    van Schie CH, Whalley A, Armstrong DG, et al: The effect of silicone injections in the diabetic foot on peak plantar pressure and plantar tissue thickness: a 2-year follow-up. .Arch Phys Med Rehabil 83::919. ,2002. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Maluf KS, Mueller MJ, Strube MJ, et al: Tendon Achilles lengthening for the treatment of neuropathic ulcers causes a temporary reduction in forefoot pressure associated with changes in plantar flexor power rather than ankle motion during gait. .J Biomech 37::897. ,2004. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Pitei DL, Foster A, Edmonds M: The effect of regular callus removal on foot pressures. .J Foot Ankle Surg 38::251. ,1999. .

  • 32

    Young MJ, Cavanagh PR, Thomas G, et al: The effect of callus removal on dynamic plantar foot pressures in diabetic patients. .Diabet Med 9::55. ,1992. .

  • 33

    Mueller MJ, Diamond JE, Sinacore DR, et al: Total contact casting in treatment of diabetic plantar ulcers: controlled clinical trial. .Diabetes Care 12::384. ,1989. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Armstrong DG, Nguyen HC, Lavery LA, et al: Off-loading the diabetic foot wound: a randomized clinical trial. .Diabetes Care 24::1019. ,2001. .

  • 35

    Caravaggi C, Faglia E, De Giglio R, et al: Effectiveness and safety of a nonremovable fiberglass off-bearing cast versus a therapeutic shoe in the treatment of neuropathic foot ulcers: a randomized study. .Diabetes Care 23::1746. ,2000. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Ha VG, Siney H, Hartmann-Heurtier A, et al: Non-removable, windowed, fiberglass cast boot in the treatment of diabetic plantar ulcers: efficacy, safety, and compliance. .Diabetes Care 26::2848. ,2003. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Ezio F, Carlo C, Giacomo C, et al: Effectiveness of removable walker cast versus non-removable fiberglass off-bearing cast in the healing of diabetic plantar foot ulcer: a randomized controlled trial. .Diabetes Care. [Published online ahead of print April 5, 2010].

    • Search Google Scholar
    • Export Citation
  • 38

    Diamond JE, Mueller MJ, Delitto A: Effect of total contact cast immobilization on subtalar and talocrural joint motion in patients with diabetes mellitus. .Phys Ther 73::310. ,1993. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Baker RE: Total contact casting. .JAPMA 85::172. ,1995. .

  • 40

    Armstrong DG, Lavery LA, Bushman TR: Peak foot pressures influence the healing time of diabetic foot ulcers treated with total contact casts. .J Rehabil Res Dev 35::1. ,1998. .

    • Search Google Scholar
    • Export Citation
  • 41

    Lin SS, Lee TH, Wapner KL: Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients: the effect of tendo-Achilles lengthening and total contact casting. .Orthopedics 19::465. ,1996. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Boulton AJ, Bowker JH, Gadia M, et al: Use of plaster casts in the management of diabetic neuropathic foot ulcers. .Diabetes Care 9::149. ,1986. .

  • 43

    Walker SC, Helm PA, Pullium G: Total contact casting and chronic diabetic neuropathic foot ulcerations: healing rates by wound location. .Arch Phys Med Rehabil 68::217. ,1987. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Sinacore DR, Mueller MJ, Diamond JE, et al: Diabetic plantar ulcers treated by total contact casting: a clinical report. .Phys Ther 67::1543. ,1987. .

  • 45

    Laing PW, Cogley DI, Klenerman L: Neuropathic foot ulceration treated by total contact casts. .J Bone Joint Surg Br 74::133. ,1992. .

  • 46

    Birke JA, Novick A, Graham SL, et al: Methods of treating plantar ulcers. .Phys Ther 71::116. ,1991. .

  • 47

    Piaggesi A, Macchiarini S, Rizzo L, et al: An off-the-shelf instant contact casting device for the management of diabetic foot ulcers: a randomized prospective trial versus traditional fiberglass cast. .Diabetes Care 30::586. ,2007. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48

    Katz IA, Harlan A, Miranda-Palma B, et al: A randomized trial of two irremovable off-loading devices in the management of plantar neuropathic diabetic foot ulcers. .Diabetes Care 28::555. ,2005. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 49

    Armstrong DG, Lavery LA, Wu S, et al: Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds: a randomized controlled trial. .Diabetes Care 28::551. ,2005. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50

    Armstrong DG, Lavery LA, Kimbriel HR, et al: Activity patterns of patients with diabetic foot ulceration: patients with active ulceration may not adhere to a standard pressure off-loading regimen. .Diabetes Care 26::2595. ,2003. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 51

    Hissink RJ, Manning HA, van Baal JG: The MABAL shoe, an alternative method in contact casting for the treatment of neuropathic diabetic foot ulcers. .Foot Ankle Int 21::320. ,2000. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 52

    Chantelau E, Breuer U, Leisch AC, et al: Outpatient treatment of unilateral diabetic foot ulcers with “half shoes.”. Diabet Med 10::267. ,1993. .

  • 53

    Knowles EA, Armstrong DG, Hayat SA, et al: Off-loading diabetic foot wounds using the scotchcast boot: a retrospective study. .Ostomy Wound Manage 48::50. ,2002. .

    • Search Google Scholar
    • Export Citation
  • 54

    Dumont IJ, Lepeut MS, Tsirtsikolou DM, et al: A proof-of-concept study of the effectiveness of a removable device for off-loading in patients with neuropathic ulceration of the foot: the Ransart boot. .Diabet Med 26::778. ,2009. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 55

    Van De Weg FB, Van Der Windt DA, Vahl AC: Wound healing: total contact cast vs. custom-made temporary footwear for patients with diabetic foot ulceration. .Prosthet Orthot Int 32::3. ,2008. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 56

    Mueller MJ, Sinacore DR, Hastings MK, et al: Effect of Achilles tendon lengthening on neuropathic plantar ulcers: a randomized clinical trial. .J Bone Joint Surg Am 85::1436. ,2003. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 57

    Piaggesi A, Schipani E, Campi F, et al: Conservative surgical approach versus non-surgical management for diabetic neuropathic foot ulcers: a randomized trial. .Diabet Med 15::412. ,1998. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 58

    Armstrong DG, Rosales MA, Gashi A: Efficacy of fifth metatarsal head resection for treatment of chronic diabetic foot ulceration. .JAPMA 95::353. ,2005. .

    • Search Google Scholar
    • Export Citation
  • 59

    Armstrong DG, Lavery LA, Vazquez JR, et al: Clinical efficacy of the first metatarsophalangeal joint arthroplasty as a curative procedure for hallux interphalangeal joint wounds in patients with diabetes. .Diabetes Care 26::3284. ,2003. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 60

    Lin SS, Bono CM, Lee TH: Total contact casting and Keller arthoplasty for diabetic great toe ulceration under the interphalangeal joint. .Foot Ankle Int 21::588. ,2000. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 61

    Nabuurs-Franssen MH, Sleegers R, Huijberts MS, et al: Total contact casting of the diabetic foot in daily practice: a prospective follow-up study. .Diabetes Care 28::243. ,2005. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 62

    Uccioli L, Faglia E, Monticone G, et al: Manufactured shoes in the prevention of diabetic foot ulcers. .Diabetes Care 18::1376. ,1995. .

  • 63

    Litzelman DK, Marriott DJ, Vinicor F: The role of footwear in the prevention of foot lesions in patients with NIDDM: conventional wisdom or evidence-based practice?. Diabetes Care 20::156. ,1997. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 64

    Dargis V, Pantelejeva O, Jonushaite A, et al: Benefits of a multidisciplinary approach in the management of recurrent diabetic foot ulceration in Lithuania: a prospective study. .Diabetes Care 22::1428. ,1999. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 65

    Viswanathan V, Madhavan S, Gnanasundaram S, et al: Effectiveness of different types of footwear insoles for the diabetic neuropathic foot: a follow-up study. .Diabetes Care 27::474. ,2004. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 66

    Reiber GE, Smith DG, Wallace C, et al: Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. .JAMA 287::2552. ,2002. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 67

    Dahmen R, Haspels R, Koomen B, et al: Therapeutic footwear for the neuropathic foot: an algorithm. .Diabetes Care 24::705. ,2001. .

  • 68

    Rizzo L, Teobaldi I, Fallani E, et al: A structured follow-up reduces the incidence of recurrences in high risk diabetic foot patients: a prospective study. Paper presented at: 8th Scientific Meeting of the Diabetic Foot Study Group; September 11–14. ,2008. ; Pisa, Italy. Abstract O-26.

  • 69

    Mueller MJ, Sinacore DR, Hastings MK, et al: Impact of achilles tendon lengthening on functional limitations and perceived disability in people with a neuropathic plantar ulcer. .Diabetes Care 27::1559. ,2004. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 70

    Salsich GB, Mueller MJ, Hastings MK, et al: Effect of Achilles tendon lengthening on ankle muscle performance in people with diabetes mellitus and a neuropathic plantar ulcer. .Phys Ther 85::34. ,2005. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 71

    Maciejewski ML, Reiber GE, Smith DG, et al: Effectiveness of diabetic therapeutic footwear in preventing reulceration. .Diabetes Care 27::1774. ,2004. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 72

    Bus SA, Valk GD, van Deursen RW, et al: The effectiveness of footwear and off-loading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review. .Diabetes Metab Res Rev 24: (suppl 1):S162. ,2008. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 73

    Owings TM, Apelqvist J, Stenstrom A, et al: Plantar pressures in diabetic patients with foot ulcers which have remained healed. .Diabet Med 26::1141. ,2009. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 74

    International Working Group on the Diabetic Foot: The International Consensus on the Management and Prevention of the Diabetic Foot [DVD], Amsterdam, the Netherlands, International Working Group on the Diabetic Foot. ,2007. .

  • 75

    Margolis DJ, Kantor J, Berlin JA: Healing of diabetic neuropathic foot ulcers receiving standard treatment: a meta-analysis. .Diabetes Care 22::692. ,1999. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 76

    Wu SC, Jensen JL, Weber AK, et al: Use of pressure offloading devices in diabetic foot ulcers: do we practice what we preach?. Diabetes Care 31::2118. ,2008. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 77

    Fife CE, Carter MJ, Walker D: Why is it so hard to do the right thing in wound care?. Wound Repair Regen. . In press.

  • 78

    Prompers L, Huijberts M, Apelqvist J, et al: Delivery of care to diabetic patients with foot ulcers in daily practice: results of the Eurodiale Study, a prospective cohort study. .Diabet Med 25::700. ,2008. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 79

    Cavanagh PR, Lipsky BA, Bradbury AW, et al: Treatment for diabetic foot ulcers. .Lancet 366::1725. ,2005. .

  • 80

    Hinchliffe RJ, Valk GD, Apelqvist J, et al: A systematic review of the effectiveness of interventions to enhance the healing of chronic ulcers of the foot in diabetes. .Diabetes Metab Res Rev 24: (suppl 1):S119. ,2008. .

    • PubMed
    • Search Google Scholar
    • Export Citation

Off-loading the Diabetic Foot for Ulcer Prevention and Healing

Peter R. Cavanagh PhD, DSc1 and Sicco A. Bus PhD2
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  • 1 Department of Orthopaedics Sports Medicine, University of Washington, Seattle, WA.
  • | 2 Department of Rehabilitation, Academic Medical Center, Amsterdam, the Netherlands.
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Retrospective and prospective studies have shown that elevated plantar pressure is a causative factor in the development of many plantar ulcers in diabetic patients and that ulceration is often a precursor of lower-extremity amputation. Herein, we review the evidence that relieving areas of elevated plantar pressure (off-loading) can prevent and heal plantar ulceration.

There is no consensus in the literature concerning the role of off-loading through footwear in the primary or secondary prevention of ulcers. This is likely due to the diversity of intervention and control conditions tested, the lack of information about off-loading efficacy of the footwear used, and the absence of a target pressure threshold for off-loading. Uncomplicated plantar ulcers should heal in 6 to 8 weeks with adequate off-loading. Total-contact casts and other nonremovable devices are most effective because they eliminate the problem of nonadherence to recommendations for using a removable device. Conventional or standard therapeutic footwear is not effective in ulcer healing. Recent US and European surveys show that there is a large discrepancy between guidelines and clinical practice in off-loading diabetic foot ulcers. Many clinics continue to use methods that are known to be ineffective or that have not been proved to be effective while ignoring methods that have demonstrated efficacy.

A variety of strategies are proposed to address this situation, notably the adoption and implementation of recently established international guidelines, which are evidence based and specific, by professional societies in the United States and Europe. Such an approach would improve the often poor current expectations for healing diabetic plantar ulcers. (J Am Podiatr Med Assoc 100(5): 360–368, 2010)

Corresponding author: Peter R. Cavanagh, PhD, DSc, Department of Orthopaedics Sports Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195-6500. (E-mail: cavanagh@uw.edu)