Offloading is arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer in a person with diabetes. Following these recommendations will help health care professionals and teams provide better care for diabetic patients who
have a foot ulcer and are at risk for infection, hospitalization, and amputation.

Using these recommendations will help health care professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer-free days, and to reduce the patient and health care burden of diabetic foot disease.

• Ontario HQ. Fibreglass Total contact casting, removable cast walkers, and irremovable cast walkers to treat diabetic neuropathic foot ulcers: a health technology assessment. Ont Health Technol Assess Ser. 2017;17(12):1-124.
• Wukich DK, Motko J. Safety of total contact casting in high-risk patients with neuropathic foot ulcers. Foot Ankle Int. 2004;25(8):556-560.
• Piaggesi A, Macchiarini S, Rizzo L, et al. An off-the-shelf instant contact casting device for the management of diabetic foot ulcers—a randomized prospective trial versus traditional fiberglass cast. Diabetes Care. 2007;30(3):586-590.

Ulcer Healing
At 3 months’ follow-up, the percentage of patients with a healed ulcer was between 74% and 95% for total contact casting, and between 80% and 85% for irremovable cast walkers. There was no statistically significant difference between the two groups when we combined the results of the studies. Note at 3 mths, not all patients are closed. 

Ontario HQ. Fibreglass Total contact casting, removable cast walkers, and irremovable cast walkers to treat diabetic neuropathic foot ulcers: a health technology assessment. Ont Health Technol Assess Ser. 2017;17(12):1-124.

•  Ha Van G, Michaux C, Parquet H, Bourron O, Pradat-Diehl P, Hartemann A. Treatment of chronic plantar ulcer of the diabetic foot using an irremovable windowed fibreglass cast boot: prospective study of 177 patients. Diabetes Metab Res Rev. 2015;31(7):691-698.
• Ha Van G, Siney H, Hartmann-Heurtier A, Jacqueminet S, Greau F, Grimaldi A. Nonremovable, windowed, fiberglass cast boot in the treatment of diabetic plantar ulcers: efficacy, safety, and compliance. Diabetes Care. 2003;26(10):2848-2852.
• Mueller MJ, Diamond JE, Sinacore DR, et al. Total contact casting in treatment of diabetic plantar ulcers. Controlled clinical trial. Diabetes Care. 1989;12(6):384-388.
• Udovichenko O, Galstyan G. Efficacy of removable casts in difficult to off-load diabetic foot ulcers: a comparative study. Diabetic Foot J. 2006;9(4):204-208.
• Van De Weg FB, Van Der Windt DA, Vahl AC. Wound healing: total contact cast vs. custom-made temporary footwear for patients with diabetic foot ulceration. Prosthet Orthot Int. 2008;32(1):3-11.

Core principals for writing prescriptions include keeping them simple, actionable, and balanced for the patient and their conditions. 

• Woo KY. Chronic wound-associated pain, psychological stress, and wound healing. Surg Technol Int. 2012 Dec;22:57-65. PMID: 23023574.
• Kiecolt-Glaser JK, Loving TJ, Stowell JR, Malarkey WB, Lemeshow S, Dickinson SL, Glaser R. Hostile marital interactions, proinflammatory cytokine production, and wound healing. Arch Gen Psychiatry. 2005 Dec;62(12):1377-84. doi: 10.1001/archpsyc.62.12.1377. PMID: 16330726.
• Norman D. The effects of stress on wound healing and leg ulceration. Br J Nurs. 2003 Nov 27-Dec 10;12(21):1256-63. doi: 10.12968/bjon.2003.12.21.11883. PMID: 14685115.
• Gouin JP, Kiecolt-Glaser JK, Malarkey WB, Glaser R. The influence of anger expression on wound healing. Brain Behav Immun. 2008;22(5):699-708. doi:10.1016/j.bbi.2007.10.013
• Gouin JP, Kiecolt-Glaser JK. The impact of psychological stress on wound healing: methods and mechanisms. Crit Care Nurs Clin North Am. 2012;24(2):201-213. doi:10.1016/j.ccell.2012.03.006
• Charalambous C, Vassilopoulos A, Koulouri A, et al. The Impact of Stress on Pressure Ulcer Wound Healing Process and on the Psychophysiological Environment of the Individual Suffering from them. Med Arch. 2018;72(5):362-366. doi:10.5455/medarh.2018.72.362-366

• Keylock T, Meserve L, Wolfe A. Low-intensity Exercise Accelerates Wound Healing in Diabetic Mice. Wounds. 2018 Mar;30(3):68-71. Epub 2017 Nov 20. PMID: 29166252.
• Eraydin Ş, Avşar G. The Effect of Foot Exercises on Wound Healing in Type 2 Diabetic Patients With a Foot Ulcer: A Randomized Control Study. J Wound Ostomy Continence Nurs. 2018 Mar/Apr;45(2):123-130. doi: 10.1097/WON.0000000000000405. PMID: 29521922.
• Smith D, Lane R, McGinnes R, O’Brien J, Johnston R, Bugeja L, Team V, Weller C. What is the effect of exercise on wound healing in patients with venous leg ulcers? A systematic review. Int Wound J. 2018 Jun;15(3):441-453. doi: 10.1111/iwj.12885. Epub 2018 Feb 15. PMID: 29446252; PMCID: PMC7950049.
• Tran MM, Haley MN. Does exercise improve healing of diabetic foot ulcers? A systematic review. J Foot Ankle Res. 2021 Mar 20;14(1):19. doi: 10.1186/s13047-021-00456-w. PMID: 33743791; PMCID: PMC7980337.

•  Dallimore SM, Kaminski MR. Tendon lengthening and fascia release for healing and preventing diabetic foot ulcers: a systematic review and meta-analysis. J Foot Ankle Res. 2015;8:33
• Mueller MJ, Sinacore DR, Hastings MK, Strube MJ, Johnson JE. Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. J Bone Joint Surg Am. 2003;85-A(8):1436- 1445
•  Bus SA, Valk GD, van Deursen RW, et al. The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review. Diabetes Metab Res Rev. 2008;24:S162-S180.
• Piaggesi A, Schipani E, Campi F, et al. Conservative surgical approach versus non-surgical management for diabetic neuropathic foot ulcers: a randomized trial. Diabet Med. 1998;15(5):412-417
• Bonanno DR, Gillies EJ. Flexor Tenotomy improves healing and prevention of diabetes-related toe ulcers: a systematic review. J Foot Ankle Surg. 2017;56(3):600-604.
• Maluf KS, Mueller MJ, Strube MJ, Engsberg JR, Johnson JE. Tendon Achilles lengthening for the treatment of neuropathic ulcers causes a temporary reduction in forefoot pressure associated with changes in plantar flexor power rather than ankle motion during gait. J Biomech. 2004;37(6):897-906.

• McLain JM, Alami WH, Glovak ZT, Cooley CR, Burke SJ, Collier JJ, Baghdoyan HA, Karlstad MD, Lydic R. Sleep fragmentation delays wound healing in a mouse model of type 2 diabetes. Sleep. 2018 Nov 1;41(11):zsy156. doi: 10.1093/sleep/zsy156. PMID: 30107617; PMCID: PMC6231532.
• Walker WH 2nd, Meléndez-Fernández OH, Nelson RJ. Prior exposure to dim light at night impairs dermal wound healing in female C57BL/6 mice. Arch Dermatol Res. 2019 Sep;311(7):573-576. doi: 10.1007/s00403-019-01935-8. Epub 2019 May 29. PMID: 31144020; PMCID: PMC7549017.
• Patt BT, Jarjoura D, Lambert L, et al. Prevalence of obstructive sleep apnea in patients with chronic wounds. J Clin Sleep Med. 2010;6(6):541-544.
• Sen CK. Wound healing essentials: let there be oxygen. Wound Repair Regen. 2009;17(1):1-18. doi:10.1111/j.1524-475X.2008.00436.x
• Bassett SM, Lupis SB, Gianferante D, Rohleder N, Wolf JM. Sleep quality but not sleep quantity effects on cortisol responses to acute psychosocial stress. Stress. 2015;18(6):638-644. doi:10.3109/10253890.2015.1087503

• Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the newest vital sign [published correction appears in Ann Fam Med. 2006 Jan-Feb;4(1):83]. Ann Fam Med. 2005;3(6):514-522. doi:10.1370/afm.405
• The Newest Vital Sign Test

• Realistic Medicine plan of care with shared decision making and outcomes.
• Sample Patient’s POC worksheet