For example, it’s well known and supported in the medical literature that allowing a foot ulcer to dry out is not conducive to healing. This is one of the reasons wet to dry dressings are a thing of the past. Similarly, appropriately offweighting a neuropathic ulcer is a well-established standard of care. Let’s make my position clear: there are appropriate offweighting methods for DFUs, and allowing a patient to wear shoes is NOT one of them.

Am I splitting hairs here? You might think so, but I can’t tell you how many times I’ve seen patients whose prior physician was treating them with regular (sometimes prescription) shoes and offweighting pads. In 2016, all of us should understand what the evidence says about various offweighting methods. To that end, let’s take a look at some of the literature and what it says about various offweighting methods.

Before we go through the evidence, here’s a nonexhaustive list of commonly used offweighting methods:

In fact, of all of these methods, the only two effective offweighting devices for most circumstances are the nonremovable cast walker and the total contact cast.

In 1997, Fleischli and associates compared the effectiveness in pressure reduction of five different offweighting methods (TTC, RCW, half-shoe, felt to foam dressing, and rigid-soled postop shoe) in 26 diabetic patients with forefoot neuropathic ulcerations (19 ulcers under the forefoot and 7 under the hallux). They evaluated plantar pressures using an in-shoe pressure measurement system while patients walked in each of the five modalities. Not surprisingly, they found a significant difference in peak plantar pressures with increasing pressures as follows: RCW, TCC, half shoe, felt-to-foam, postop shoe. The amount of pressure reduction between methods was also significant, with the following decreased pressures from baseline¹:

This study looked at a relatively small number of patients, though by crossing over the patients into each modality, they essentially used the group as its own control. This strengthens the quality of the study and makes it more valid for our discussion.

Now pressures are one thing, but how do offweighting methods compare for actual patient outcomes? In 2001, Armstrong and associates studied the effectiveness of total contact casts, removable cast walkers, and half-shoes for ulcer healing. They prospectively randomized 63 diabetic patients with neuropathic ulcers to one of each of these options. The researchers performed weekly wound debridement and ulcer care and tracked wound size by planimetry. Their primary outcome was the percentage of wound healing at 12 weeks and was: 89.5% (total contact cast), 65.0% (removable cast walker), and 58.3% (half-shoe). Among those patients with healing at 12 weeks, those in the TCC healed faster than those in the half-shoe (33.5 ± 5.9 days versus 61.0 ± 6.5 days, respectively)².

Not convinced yet? In Part 2 of our discussion, we’ll review further evidence that reveals just how well the TCC and its progeny perform compared with more commonly used modalities in offweighting diabetic foot ulcers. We’ll also discuss a more practical method to offweight these lesions.

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