A survey of offloading practices for diabetes-related plantar neuropathic foot ulcers

Background: Offloading is key to preventing or healing plantar neuropathic foot ulcers in diabetes. Total contact casts or walkers rendered irremovable are recommended in guidelines as first- line options for offloading, however the use of such devices has been found to be low. This study aimed to investigate offloading practices for diabetes-related plantar neuropathic ulcers. Methods: An online survey of closed and open-ended questions was administered via SurveyMonkey r. Forty-one podiatrists experienced in high-risk foot practice, from 21 high-risk foot services around Australia, were approached to participate. Results: The response rate was 88%. Participants reported using 21 modalities or combinations of modalities, for offloading this ulcer type. The most frequently used modalities under the forefoot and hallux were felt padding, followed by removable casts or walkers, then non-removable casts or walkers. Participants indicated that many factors were considered when selecting offloading modality, including: compliance, risk of adverse effects, psycho-social factors, restrictions on activities of daily living, work needs and features of the wound. The majority of participants (83%) considered non-removable casts or walkers to be the gold-standard for offloading this ulcer type, however they reported numerous, particularly patient-related, barriers to their use. Conclusions: Selecting offloading for the management of foot ulceration is complex. Felt padding, not the gold-standard non-removable cast or walker, was reported as the most commonly selected modality for offloading plantar neuropathic ulceration. However, further evaluation of felt padding in high quality clinical trials is required to ascertain its effectiveness for ulcer healing.