Regular callus
removal should be
performed in people with
diabetes and neuropathy
by a skilled health care
provider.
Footwear
Patients with an
at-risk diabetic foot
should be urged not to
walk barefoot but to
wear protective footwear
both at home and
outside.
Although no evidence
exists, it is often
apparent clinically that
even extra-depth
footwear may not
accommodate a foot with
significant deformity.
In such cases, custom
footwear is recommended.
Therapeutic shoes
can be used for
preventing plantar
ulceration in the
at-risk diabetic foot.
To achieve maximal
reduction of peak
plantar pressures in
footwear prescription,
custom molded insoles
should be incorporated
in the therapeutic
footwear as long as
sufficient space exists
(see, for example,
'Extra-depth shoe' in
Appendix).
Surgical offloading
Given the paucity of
data, no definitive
statement can be made
about the effectiveness
and safety of preventive
surgery.
Achilles tendon
lengthening can be
considered in selected
patients but this
procedure carries the
risk of heel ulceration.
More information,
including high quality
studies, is needed
before the procedure can
be recommended for
widespread use.
There are few high
quality studies on
metatarsophalangeal
(MTP) joint arthroplasty
and metatarsal head
(MTH) resection. These
approaches cannot be
recommended for
widespread use before
further evidence is
available.
One should also be
aware of the
disadvantages of
applying surgical
techniques for the
prevention of plantar
ulcers in the diabetic
foot which can include
post-operative wound
infection, induction of
acute
neuro-osteoarthropathy
(Charcot) and
development of ulcers at
other sites (transfer
ulcers).
Treatment of ulceration:
Offloading
The total contact
cast (TCC - see
Appendix) is the
preferred treatment for
non-infected,
neuropathic diabetic
plantar forefoot ulcers
in patients with no
signs of critical limb
ischemia.
Adverse effects of
TCC include:
immobilisation of the
ankle, reduced activity
level, difficulty with
sleeping or driving a
car, and pressure ulcers
due to poor casting
technique.
If casting is not
available, then
removable walkers with
an appropriate interface
should be considered.
Preferably, these
walkers should be made
irremovable as this
'forced adherence'
increases healing rates.
The use of
half-shoes or cast shoes
for neuropathic plantar
ulcer treatment is
recommended if TCC or
below knee removable
walkers are
contra-indicated or
cannot be tolerated by
the patient.
Footwear
Conventional or
standard therapeutic
shoes should not be
chosen for treatment of
plantar foot ulcers as,
usually, there are many
devices available that
are more effective.
Non-plantar ulcers
and post-surgical wounds
also need relief of
mechanical stress.
Depending on the
location of the ulcer,
various modalities can
be considered, including
shoe modifications,
temporary footwear, and
toe spacers.
Surgical offloading
More studies are
needed to better define
the role of surgical
off-loading compared to
conservative treatment
and one should be aware
of the disadvantages of
applying surgical
techniques for the
treatment of plantar
ulcers in the diabetic
foot (see above).
Other offloading
interventions
If other forms of
biomechanical relief are
not available, felted
foam in combination with
appropriate footwear can
be used to provide
accommodative
off-loading at an ulcer
site. It should not be
used as a single
treatment method.
