Relieving pressure from the ulcer is a key component of care. In fact, without some attempt to address this issue wound care will at best be compromised and at worst ineffective. Providing equipment, such as crutches or a wheelchair, will encourage the most effective approach which is non-weight-bearing. In most cases this is difficult to achieve and at best patients will reduce their activities, especially when faced with living with a potentially chronic wound. Listening to the patient and negotiating a workable approach to this issue is of course the best approach. Complete pressure relief (i.e. no pressure taken on the area) is difficult to achieve with the majority of devices used, particularly when addressing weight-bearing areas of the foot hence, pressure reduction is the ‘realistic’ aim of intervention.
Unfortunately there is not a wealth of research literature available that compares approaches commonly used to address this issue. However, the International Working Group on the Diabetic Foot6,7 recommends consideration of the use of a total contact casting (TCC) in treatment of neuropathic, non-infected, non-ischaemic plantar diabetic foot ulcers and this is often regarded as the gold standard based on the available evidence. Further advice given by this group suggests cast shoes and cast boots as alternative modalities.
If neuroischaemic ulceration is also considered, the Scotchcast boot is an option13. More recently, synthetic semi rigid casting techniques, involving the use of slipper casts and below knee casts, have been trialled as an alternative with both neuropathic and neuroischaemic foot ulcers4. Adhesive felt aperture padding, directly adhered to the skin, is not currently recommended for use in the management of foot ulceration due to infection control issues.
Removable walkers are an alternative to casting techniques. However, the removable nature of these devices reduces their effectiveness and it is recommended by the IWGDF that they are made ‘irremovable’ to increase healing percentages to a level comparable with the TCC.
During active ulceration, therapeutic footwear (i.e. stock or bespoke ‘orthopaedic’ footwear) is not recommended but may be the only approach for some very complex cases. An alternative to this is a bespoke removable walker in cases of significant deformity and severely altered foot and leg biomechanics.
The final choice of pressure relief or reduction modality will depend on the available evidence and a variety of factors, including ease of use, safety and appropriateness for all activities (e.g. bed, sitting and transferring). Ultimately the approach must work in conjunction with dressing choice – dressings contribute to protecting the foot but do not provide pressure relief.