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Pressure Off-loading a Diabetic Foot

Delayed healing of diabetic plantar ulcers is caused primarily by inadequate or inappropriate wound off-loading9

Reduction of pressure and shear forces on the foot may be the single most important – and most neglected – aspect of treating neuropathic ulcers.

Diabetic foot ulcers are commonly associated with the presence of peripheral neuropathy20 and repetitive trauma to areas of the foot exposed to moderate or high pressure due to normal walking activities.10

Foot deformities, limited joint mobility, partial foot amputations, and other structural deformities often predispose diabetic persons with peripheral neuropathy to abnormal weight bearing, areas of concentrated pressure that significantly increase their risk of ulceration.5,11

For the non-ischemic, non-infected neuropathic diabetic foot ulcer, the accepted hallmarks of care include appropriate debridement, meticulous wound care, nutrition, and adequate relief of pressure.7

Pressure reduction, commonly known as "off-loading," is most successful when force is spread over a wide area. Efficacious pressure mitigation depends on three factors: the pressure reduction modality, patient compliance, and biomechanics.12,21

Off-loading strategies must be tailored to the age, strength, activity, and home environment of the patient. In general, however, more restrictive off-loading approaches will result in less activity and better wound healing.10

Methods of off-loading the foot include total contact casting (TCC), removable walking boots, healing sandals, half-shoes, and ankle-foot orthoses. Considered the gold standard for off-loading the foot, TCC reduces pressure at the ulcer site while allowing the patient to remain ambulatory.13,7

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