01Purpose and principlesWhat the treatment does and how it fits into care.
Neuropathic ulcers persist because repetitive mechanical stress exceeds the repair capacity of insensate tissue. The stress may be plantar pressure at a metatarsal head, shear at a foot margin, rubbing over a dorsal toe or sustained pressure at the heel in bed. Removing only callus or changing a dressing leaves the causal load in place. Effective offloading redistributes force, limits ankle motion and, when non-removable, improves adherence by ensuring the device is worn during weight-bearing.
Device choice follows ulcer location and complication status. A non-removable knee-high device is preferred for an uncomplicated neuropathic plantar forefoot or midfoot ulcer. Infection, ischaemia, heavy exudate, need for frequent inspection, fluctuating oedema, balance problems or intolerance may require a removable device or temporary non-weight-bearing. Wound care simultaneously controls devitalised tissue, exudate and peri-wound damage, while infection and ischaemia receive their own treatment. Healing failure should trigger a search for continued pressure, poor adherence, occult infection, inadequate perfusion or the wrong diagnosis.
Key points
- For an uninfected, non-ischaemic neuropathic plantar forefoot or midfoot ulcer, use a non-removable knee-high offloading device when safe and acceptable, with an interim alternative if casting is not immediately available.
- Do not seal a moderate or severe infected or ischaemic ulcer inside a non-removable device; treat the complication first and choose removable offloading that permits the required inspection and wound care.
- Sepsis, gangrene, deep infection or limb ischaemia requires immediate acute referral and multidisciplinary coordination; offloading must never delay drainage, antibiotics or revascularisation.
- Offloading is an active dose of pressure reduction: device efficacy depends on correct fit, use during every weight-bearing step and prompt management of adverse effects.
- Choose dressings to maintain an appropriate moist environment, control exudate and protect surrounding skin; expensive or antimicrobial products do not substitute for pressure relief and perfusion.
- Sharp debridement frequency follows clinical need and specialist skill; extensive hospital debridement belongs with the multidisciplinary foot service, particularly when perfusion is uncertain.
- A removable knee-high or ankle-high device is the next option when non-removable treatment is contraindicated or not tolerated; explain that removal during walking reduces benefit.
- Monitor at least weekly when mild infection or ischaemia accompanies offloading, and more frequently when exudate, wound care or clinical instability demands access.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
A callused ulcer under a metatarsal head or midfoot prominence with loss of protective sensation indicates repetitive vertical and shear load. Define the exact site, deformity, gait and footwear before selecting a device.
Erythema, purulence, heavy exudate, necrosis, coolness, abnormal Doppler signals or perfusion deficits alter offloading safety and the required inspection interval. Grade infection and ischaemia before making a device non-removable.
Dorsal toe, interdigital, heel or foot-margin ulcers require removal of local contact through footwear modification, toe spacers, orthoses or another site-specific intervention. A plantar device chosen by habit may miss the causal force.
New rubbing, blistering, edge pressure, gait instability, falls, knee or hip pain and contralateral limb overload show that offloading has shifted rather than safely reduced stress. Inspect both limbs and the device at review.
Failure of area and depth to improve despite apparent care should prompt direct questions about device use for every step, fit and activity, followed by reassessment for infection, osteomyelitis, ischaemia and wound-bed barriers.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Full complication screen before offloadingFirst step - Why
- Detect infection, ischaemia, deep tissue involvement and heavy exudate that change device choice or demand urgent referral.
- Interpretation and limitations
- Severe infection or ischaemia, gangrene or deep collection requires immediate specialist care. Moderate infection or ischaemia and frequent wound access generally favour removable offloading while the complication is treated.
- 02
Ulcer measurement and pressure map - Why
- Define wound site, area, depth, tissue quality and the mechanical structure producing repeated stress.
- Interpretation and limitations
- Measure length, width and depth and document callus, undermining and exposed structures. Relate a plantar lesion to bony prominence and gait; relate a non-plantar lesion to footwear, adjacent toes, bed pressure or device edges.
- 03
Neurological and vascular assessment - Why
- Confirm loss of protective sensation and determine whether perfusion can support debridement and healing.
- Interpretation and limitations
- Use monofilament plus another sensory test and combine pedal Doppler waveforms with ABPI and toe-based pressures. A high ABPI may be artefactual; suspected significant PAD needs vascular input.
- 04
Device and gait assessment - Why
- Check whether the intervention actually reduces load without creating instability or new injury.
- Interpretation and limitations
- Inspect fit, liners, closures, wear pattern and the skin after use. Observe transfers and walking, assess falls risk and leg-length discrepancy, and add a contralateral shoe lift or walking aid when appropriate.
- 05
Healing trajectory - Why
- Detect early failure and decide whether to revise offloading, wound care, infection control or perfusion management.
- Interpretation and limitations
- Plot serial area and depth with consistent technique. Static or worsening measurements, new necrosis, exudate or inflammation require prompt reassessment rather than repeated use of the same dressing.
04Treatment approachPreparation, options, escalation and aftercare.
01Core pathwayUncomplicated plantar forefoot or midfoot ulcerFirst stepA neuropathic plantar ulcer is uninfected, non-ischaemic and suitable for knee-high device treatment.+
- 1Offer a non-removable knee-high device, either a total contact cast or suitably rendered non-removable walker, applied by a trained service after skin, perfusion, balance and consent assessment.
- 2AlternativeProvide an alternative offloading device until casting is available, explain use during all weight-bearing, limit unnecessary steps and arrange early inspection for fit, rubbing and wound response.
- 3At each review debride callus or devitalised tissue when appropriate, use a simple exudate-matched dressing, inspect the opposite foot and repair or replace a damaged device.
- 4EscalationIf healing stalls, verify adherence and effective load reduction, then reassess infection, osteomyelitis and perfusion before escalating adjunctive wound products or surgery.
02Preferred branchInfection or ischaemia changes offloadingPreferredMild complications need closer surveillance, or moderate to severe infection, ischaemia or heavy exudate requires frequent access.+
- 1With mild infection or mild ischaemia, individualise the device and inspect at least weekly; a non-removable option may be possible only when access and safety remain adequate.
- 2With both mild infection and mild ischaemia, moderate complication, heavy exudate or frequent wound care, avoid non-removable offloading and use a removable intervention matched to function.
- 3With severe infection or ischaemia, prioritise acute treatment and source control; protect from load with a compatible removable device or temporary non-weight-bearing, then step up offloading as the complication improves.
03Wound bedDebridement and dressing sequenceDevitalised tissue, callus, exudate or peri-wound maceration impedes assessment or healing after urgency and perfusion are addressed.+
- 1Use skilled sharp debridement according to clinical need, ulcer location, perfusion and patient preference; community care must follow the multidisciplinary treatment plan and practitioner competence.
- 2Choose a low-acquisition-cost dressing suited to moisture, protection and atraumatic removal; protect peri-wound skin and avoid routine topical antiseptic or antimicrobial dressings solely to accelerate healing.
- 3Consider selected adjuncts only after standard care has been optimised and healing remains inadequate, with multidisciplinary advice and awareness that NICE and IWGDF recommendations differ for some technologies.
04Other sitesNon-plantar and rearfoot ulcersThe ulcer is on a toe, interdigital space, foot margin, dorsal surface or heel rather than the plantar forefoot or midfoot.+
- 1Identify the exact contact or pressure source and choose removable devices, footwear modification, toe spacers or orthoses that eliminate stress at that location without causing new lesions.
- 2For a neuropathic plantar rearfoot ulcer, consider a non-removable knee-high device when complication status and safety permit, recognising the evidence is very uncertain.
- 3Reassess the skin after use, bed and chair positioning, gait and transfers; modify the intervention whenever pressure has simply moved elsewhere.
05Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Review wound dimensions, depth, tissue, exudate and peri-wound skin with a consistent method; increase frequency for infection, ischaemia, heavy drainage or deterioration.
- Remove and inspect removable devices and, at scheduled trained reviews, non-removable devices; check edges, liners, fit, odour, wetness and new pressure injury on both feet.
- Ask specifically how many steps occur without the device, including night-time bathroom trips and indoor walking, because partial adherence can maintain damaging cumulative stress.
- Assess walking stability, falls, transfer safety, leg-length discrepancy and contralateral limb load; add a shoe lift or mobility aid when clinically appropriate.
- Escalate immediately for fever, spreading inflammation, new necrosis, coolness, gangrene, severe pain, systemic illness or rapidly increasing exudate, and reassess any stalled healing.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Adherence explains efficacy
A removable walker may reduce pressure well in the laboratory yet fail clinically if removed for many steps. Rendering an appropriate walker non-removable converts recommended use into consistent use, but only when frequent inspection is unnecessary.
Complications create a ladder
Mild infection or ischaemia may allow closely monitored knee-high offloading. Moderate disease, combined complications or heavy exudate usually demands removability. Severe disease shifts priority to infection or perfusion treatment while pressure protection continues compatibly.
Debridement needs perfusion context
Removing callus exposes true wound dimensions and reduces pressure, but aggressive debridement of dry ischaemic tissue can enlarge a non-healing defect. Vascular status, tissue viability and source-control need determine timing and extent.
Dressings manage an environment
A dressing should handle exudate, preserve moisture balance, protect surrounding skin and permit atraumatic change. It cannot compensate for continuing load, untreated infection or inadequate arterial inflow.
Guidelines may diverge
NICE advises hyperbaric oxygen only in a clinical trial for diabetic foot ulcers, while IWGDF 2023 conditionally considers it for selected neuro-ischaemic ulcers after standard care fails. UK practice should follow applicable governance and specialist selection.
07Common pitfallsFrequent interpretation and management errors.
- 01
Choosing a cast before grading infection and ischaemia can hide deterioration and obstruct the frequent access a complicated wound requires.
- 02
Calling a removable device ineffective without checking whether it was worn during every step confuses adherence failure with mechanical failure.
- 03
Escalating to expensive dressings while plantar pressure continues wastes time and may allow deeper tissue loss.
- 04
Debriding an ischaemic wound aggressively without vascular assessment may convert stable dry tissue into a larger defect with little healing capacity.
- 05
Focusing only on the ulcerated foot misses contralateral pressure injury, falls and gait changes created by a bulky knee-high device.