Foot ulcers related to diabetic neuropathy are one of the leading causes of hospitalisation, amputation, disability, and healthcare burden. According to a 2023 systematic review by Lazzarini et al.,^[1] the most common cause in the development of a diabetic foot ulcer is high plantar tissue stress on a foot with peripheral neuropathy. A diabetic foot ulcer that is not managed with appropriate off-loading interventions has an increased likelihood of becoming non-healing, developing infection, requiring hospitalisation, and amputation. Therefore, offloading is an important and longstanding treatment in the care and prevention of diabetic foot ulcers.^[1]

Determining the most appropriate footwear for a patient with peripheral neuropathy requires a thorough and complete foot assessment. It falls on the wound care or rehabilitation professional to make sure a patient’s chosen footwear fits appropriately, especially if they do not have intact sensation.^[2]

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Evaluate the fit of a shoe with the patient in standing and preferably later in the day when feet are more likely to be swollen. Footwear should be sufficiently sized to accommodate the foot without excessive pressure on the skin:

• the inside length of the shoe should be 1-2 cm longer than the patient’s foot
• the inside width should equal the width of the foot at the metatarsophalangeal joints (or the widest part of the foot)
• the inside height should allow enough room for all the toes to rest naturally

Refer the patient for specialised or customised footwear if:

• off-the-shelf footwear that can accommodate the foot is not available
• there are signs of abnormal loading of the foot in standing or during gait

Proper and effective offloading is key to healing foot ulcers. There are many options for offloading, ranging from therapeutic footwear to limiting gait with wheelchair use.^[1] The basic components of proper offloading the foot involve:^[2]

1. redistrubuting weight bearing forces across the enrire plantar surface of the foot
2. assisting in supporting the lower leg throughout the gait cycle
3. decreasing over all activity even when wearing an offloading device

According to the 2019 update from the International Working Group on the Diabetic Foot (IWGDF), any individual who is at moderate risk for developing a diabetic foot ulcer or currently has an active foot ulcer should wear therapeutic footwear that accommodates their foot shape and fits appropriately.^[2][3] Patients who are at greatest risk for the development of a foot ulcer or who have a history of healed ulcers benefit from the use of the most advanced offloading devices available. Patients who have healed ulcers will require continued use of offloading footwear to prevent ulcer reformation and limit callus buildup.^[2]

Table 1.

Method	Description	Removable by patient? If not, frequency of change	Benefits	Risks or Negatives
Most Effective Methods
Total Contact Cast (TCC)	Considered the gold standard in offloading[4] Has minimal padding Conforms to the shape of the foot and leg Helps support the entire lower extremity below the knee[2]	No, not removable by patient Requires skilled application Frequency of change: once a week	Most effective method to offload the foot[2] and the first choice treatment option by the IWGDF[4] Protects the foot from additional trauma and deformity[4] Promotes tissue repair[4] Forces the patient to be compliant with offloading	Risk of skin breakdown if not applied correctly Can hinder mobility and cause muscle stiffness and joint atrophy with prolonged use[4] Contraindicated for patients who have untreated or active osteomyelitis or an untreated soft tissue infection[2]
Irremovable Knee-high Cast Boot or Offloading Boot[2](removable walker boot[3]or removable cast walker[4])	Off-the-shelf device Designed with a special plantar footplate that will help offload the foot	Yes, removable by patient BUT can be made irremovable by applying casting material over the velcro straps Does not require skilled application Frequency of change: once a week	Many studies show it has an equal outcome to the total contact cast[1] Easy removability allows for wound assessments and care[4] Allows for more comfortable movement in daily life[4] Tends to be better tolerated by the patient as compared to the total contact cast	Risk of skin breakdown if not fitted correctly If patient is not compliant with wearing, has a significantly lower healing ability as compared to the TCC[4]
Charcot Restraint Orthotic Walker (CROW)[2]	Custom-moulded to the patient’s foot and leg Built of very durable material Secured with velcro straps	Yes, removable by patient BUT can be made irremovable by applying casting material over the velcro straps if needed	Very effective in offloading	Expensive to produce
Less Effective Methods
Cast Shoe or Post-op Shoe[2]	Solid plantar surface to protect the plantar aspect of the foot Apply felted foam[1] or “football dressing” around the area needing off-loading	Yes	Inexpensive option	Felted foam can ONLY be used in combination with appropriate footwear[3]
Wedge Shoe or Half-shoe[2]	The forefoot does not have plantar support other than a small shelf for the forefoot and the toes to rest upon All weight bearing is forced through the heel	Yes	Can be very effective in offloading the forefoot or the toes if utilised appropriately	Requires a lot of education and training to alter gait mechanics for proper offloading

Other Off-Loading Considerations[edit | edit source]

When a patient with an at-risk foot has no active foot ulcers and/or has achieved healing of past wounds, they should be placed in appropriate long-term offloading footwear.^[2] Other options to consider include:

Custom-moulded shoe insert. These inserts redistribute pressure from body weight throughout the plantar surface of the foot. Allows patient to wear their own shoes, and gives them the option to wear different shoes while decreasing the risk of developing or redeveloping a wound.

Foot orthosis. Fills in the space in a patient’s shoe due to a toe or partial foot amputation. This allows the shoe to fit more appropriately and improves gait dynamics.

Semi-rigid orthotic. These orthotics are useful for pressure reduction over calluses on the weight-bearing surface of the foot.

Rigid rocker bottom sole. Improves gait dynamics by promoting roll over of the entire plantar surface with improved push-off. This style of shoe sole puts the propulsion point behind instead of over the metatarsal heads to aid in offloading throughout the gait cycle.

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  Charcot Restraint Orthotic Walker (CROW)

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Rehabilitation professionals, such as physiotherapists and occupational therapists, can establish and monitor personlised exercise programmes, assist wound care professionals by inspecting the state of the patient’s feet, and provide important patient and care provider education.^[2]

Therapeutic Exercise[edit | edit source]

• Plays a role in preventing or counteracting peripheral artery disease (PAD) in patients with diabetes^[4]
• May improve the distance a patent can walk before they are limited by pain or muscle cramps (claudication distance) due to intermittent claudication with PAD
• Can have a significant positive effect on HbA1c reduction^[5] in patients with diabetes
• Stretching and maintaining available range of motion of the Achilles tendon and flexor hallucis^[2] is beneficial to help decrease fall risk and improve gait dynamics

Strengthening[edit | edit source]

Considerations and modifications to typical strengthening interventions may be needed:^[2]

• patient should always wear their therapeutic footwear
• precaution: make sure that additional pressure is not placed on an active wound or other high-risk areas
• perform fewer repetitions with increased frequency throughout the day to decrease repetitive stress to high-risk areas of the patient’s feet
• educate patient and/or their care providers to regularly monitor feet for signs on pressure – see education section below for more information
• perform open-chain exercises versus closed-chain exercises to further decrease plantar pressure on the foot

Endurance training[edit | edit source]

Improving cardiovascular endurance and stamina will benefit a patient’s overall health. However, cardiovascular training should be closely monitored and advanced slowly.^[2]

• patient should always wear their therapeutic footwear
• utilise upper extremity training for cardiovascular health – e.g. upper extremity bike, resistance training with elastic bands or hand/wrist weights
• utilise devices which allow for modification of lower extremity weight-bearing – e.g. rowing machine, total gym at lower angles, stationary bike
• educate patient and/or their care providers to regularly monitor feet for signs of pressure

Balance and Proprioception[edit | edit source]

Balance and proprioception often exist hand-in-hand in the clinic, and with fall prevention and gait training.

• patient should always wear their therapeutic footwear
• frequent balance and fall assessment is recommended
• please review this article for more information on balance training

Gait Training[edit | edit source]

Gait is a complicated motor task, and requires the interplay of appropriate motor control and planning, balance and multiple interacting sensory systems to be successful. A 2020 study by Ahmad et al.^[6] provides an excellent clinical example of the interconnectedness of rehabilitation interventions by showing that sensorimotor and gait training in patients with diabetic neuropathy has a positive effect on proprioception and nerve function. A holistic and thorough rehabilitation assessment is recommended for all patients, but especially those with neuropathy.

• challenge gait over different surfaces, different speeds, different stride lengths, etc
• add dual tasking and cognitive challenges
• perform regular fall and sensory assessments

Aquatic Therapy and Swimming[edit | edit source]

Using public pools is contraindicated for patients with open wounds. However, patients can use private pools with appropriate chlorination if they have open wounds. Any patient with an open wound should avoid fresh water due to infection risk. However, patients with diabetes and at-risk feet would greatly benefit from aquatic therapy interventions.^[2]

• builds endurance and strength^[2]
• bouyancy of water provides effective offloading^[2]
• improves on-land balance and gait dynamics^[7]

Thorough and frequent patient education is critical for successful wound prevention and/or healing. Patient education sessions should be presented in a way to share the greatest amount of training within a session with a high retention rate.

“Education needs to start early and be repeated often. Diabetes is an overwhelming disease, so the more you repeat things, the more different ways you educate the patient, the better your chances of getting some retention, some buy-in, and some cooperation and the follow-through.”
-Diane Merwarth PT

Tips for successful patient education:^[2]

• provide education via different methods, e.g. verbal, visual, reading, images/pictures, videos
• utilise both one-on-one or group discussions
• repetition, adjusting frequency and feedback as needed
• challenge knowledge using games or quizzes
• have patient or care provider explain education back to the educator

Education topics specific to peripheral neuropathy:^[2]

1. Therapeutic footwear. The goal is to protect the patient’s feet:
   • should be worn at all times, inside and outside
   • should never walk barefoot
   • should never walk only in socks or thin-soled slippers
   • should never walk with shoes without socks
2. Foot inspection. Please return this article for details on the steps of a foot inspection.
3. Shoe inspection:
   • look for abnormal wear patterns that indicate the need for a new pair of shoes or a gait assessment
   • look for sources of friction or abrasion inside their shoe, even through a sock
   • look for any foreign objects inside the shoe which would be a source of pressure or cause injury
4. Foot hygiene:
   • daily foot wash using soap and water, making sure to rinse all the soap off
   • dry foot thoroughly, including the web spaces
   • apply moisturiser to the skin to keep it as supple and healthy as possible. However, do not apply moisturiser between the toes
   • Adaptations:
     • low/poor vision:
       • recommend family member or care provider assistance
       • if patient has no assistance, will need to adapt by propping their foot to use sense of touch to inspect the surfaces of their feet
     • limited mobility
       • use a long-handled mirror to inspect the plantar aspect of their foot
       • use a long-handled sponge to clean their feet and show them how to loop the towel over their foot for drying
5. Nail and callus care:
   • patient and/or care providers should never cut the patient’s toenails or trim the patient’s calluses unless they can be properly trained and demonstrate competence
   • encourage patient to follow up with a podiatrist for frequent appointments to manage nails and calluses
6. Foot ulcer-specific education:
   • describe what a foot ulcer is and the signs of symptoms of one forming
   • explain the consequences of getting a foot ulcer
   • education on self-care to include foot and shoe inspection and foot hygiene
   • discuss appropriate footwear and the importance of wearing footwear all the time
   • explain when to seek professional help once they have identified an area of concern. Depending on requirements in your region of practice, it is also important to provide education on how to obtain appropriate referrals from their medical doctor.
7. Psychosocial support:
   • requires a team approach, including the patient and their care provider(s), to best manage the patient’s diabetes and to minimise their risks and have the best outcome
   • important multidisciplinary team members include: a trained psychologist or counsellor, chaplains, occupational therapy and speech therapy
8. Follow-up education:

Table 2. IWGDF Risk of Foot Ulcer Formation

Risk Category	Risk of Ulcer Formation	Characteristics	Reassessment Frequence
0	Very low		Once a year
1	Low	LOPS or PAD	Once every 6-12 months
2	Moderate	LOPS and PAD OR LOPS and foot deformity Or PAD and foot deformity	Once every 3-6 months
3	High	LOPS or PAD and one or more of the following: previous foot ulcer any lower-extremity amputation end-stage renal disease (ESRD)	Once every 1-3 months

The above table is adapted from information provided in the IWGDF 2023 update.^[8]

Patient Resources:[edit | edit source]