Offloading diabetic foot ulcers refers to some methods used to relieve pressure from an ulcerated area of the foot. Offloading an ulcer is important because excessive pressure on the foot can worsen ulcers, delay healing, and increase the risk of complications.
Unfortunately, over 80% of lower-limb amputations in diabetic patients are preceded by foot ulcers. One important method of offloading is Total contact casts (TCC). However, studies show that only 1.7% of clinics use TCCs. Moreover, about 45.5% of clinics do not use TCCs to treat diabetic foot ulcers. [1][2][3]
In this article, we will shed some light on some practical strategies for offloading diabetic foot ulcers. By the end of this post, you will learn everything there is to know about this topic.
Types of offloading devices
There are different offloading devices that suit specific types of ulcers and patient needs. The choice of the right device depends on the ulcer’s location, the patient’s mobility, and the presence of infection.
Total Contact Cast (TCC)
Total contact casts are considered the gold standard for offloading diabetic foot ulcers, especially for ulcers present on the plantar (bottom) aspect of the foot.
If you are unfamiliar with this device, it looks like a leg cast for fractures. A TCC is a specialised cast that evenly distributes pressure across the entire foot and lower leg. The goal is to keep the leg suspended and minimise pressure on the ulcerated area. According to a 2015 randomised clinical trial, the effectiveness of TCCs can heal 72% to 100% of ulcers within 5 to 8 weeks. [4]
Removable Cast Walkers (RCW)
Removable cast walkers are another option for offloading. They are removable, allowing practitioners to inspect the wound and change the dressings regularly.
Patients often prefer these devices because of their convenience. However, their effectiveness mainly depends on your compliance. Additionally, researchers found that inconsistent wear of RCW dramatically reduces the benefits of these devices. [5]
Healing sandals and half shoes
Healing sandals (i.e., post-op shoes) are special footwear that offloads pressure from the forefoot or rear foot by redistributing weight to the non-ulcerated parts of the foot. These shoes do not offload pressure as effectively as the above methods, but they are simple and easy to use. However, the effectiveness is also highly dependent on patient compliance.
Crutches and wheelchairs
For patients with severe ulcers, crutches or wheelchairs can also be an effective offloading method. These devices eliminate pressure on the foot and remove the need for the patient to walk on the ulcerated area.
How to properly effectuate offloading
Offloading is not just about the application of a device. It also involves a comprehensive approach that requires considerations such as the patient’s health, lifestyle, and specific needs.
Here are some practical steps to ensure effective offloading:
Choose the right device
The choice of the offloading device is ultimately the most important factor that affects effectiveness. However, it is almost impossible to always offer the gold standard option to every patient. We need to consider factors such as the ulcer’s location, the patient’s mobility, and the presence of any other health issues. For instance, TCCs are ideal for plantar ulcers but may not be suitable for patients with poor balance or severe infections.
Follow the right instructions
The effectiveness of offloading devices depends on their correct application. Researchers show that offloading devices may potentially create new pressure points, which can trigger new ulcers. Therefore, it’s indispensable for healthcare providers to be trained in using these devices. Only then, it will be possible for them to teach patients. [6]
Monitor and adjust regularly
The offloading device needs to be monitored. These devices may exacerbate diabetic foot ulcers when they are not used properly. An examination should focus on frequent checks for signs of new ulcers, adjustments to the device as needed, and regular dressing changes.
Educate the Patient
A multidisciplinary team will ensure the patient is properly educated about their condition. Patients must understand why they need to use the offloading device consistently. At the same time, behaviours that could compromise their treatment (e.g., walking with the device, not following wound care instructions) must be avoided.
Address compliance issues
One of the biggest challenges with offloading is patient compliance. Removable devices like RCWs are less effective if patients do not wear them consistently. Therefore, it is vital to emphasise the importance of wearing the device clearly and consistently during regular follow-up appointments.
Why multidisciplinary care for diabetic foot ulcers is important?
The successful management of diabetic foot ulcers requires a multidisciplinary approach. This involves the collaboration between various healthcare providers, including podiatrists, orthopaedic surgeons, vascular surgeons, endocrinologists, and nurses. Each professional plays a role in ensuring the ulcer is treated effectively.
The central points of multidisciplinary care:
- Frequent foot examinations by healthcare providers.
- Infection control involves rapid treatment of any infections.
- Proper wound care and dressing applications.
- Patient education about foot care and the importance of offloading
Takeaway message
Offloading is a cornerstone of diabetic foot ulcer treatment. This method reduces the pressure on the ulcer and accelerates wound healing. We understand that the different offloading methods may be overwhelming for you. However, the key to success is wearing the device correctly and following instructions.
Hopefully, this article helps you understand the importance of offloading diabetic foot ulcers and how to practice it.
If you are or know someone facing difficulty dealing with diabetic foot ulcers, feel free to contact us. Our multidisciplinary team at Nobel Diabetic Foot Care will strive to provide a holistic management plan tailored to your needs.
References
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10723802/
- https://www.hmpgloballearningnetwork.com/site/wounds/article/clinical-and-economic-benefits-healing-diabetic-foot-ulcers-rigid-total-contact-cast
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2571059/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7950500/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9837274/
- https://www.researchgate.net/publication/366439273_Offloading_Devices_for_the_Prevention_of_Heel_Pressure_Ulcers_A_Realist_Evaluation
