Synopsis
Match offloading and wound care to ulcer location, infection, perfusion, exudate and the person's mobility so mechanical stress falls without concealing deterioration.
- 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.
Key red flags
Fever, spreading erythema, systemic illness, crepitus, bullae, purulent tracking or severe pain requires urgent reassessment and possible acute referral.
New coolness, pallor, mottling, gangrene, absent Doppler signals or rapidly enlarging necrosis suggests worsening ischaemia and needs urgent vascular review.
A cast-associated new pain, odour, wetness, swelling, rubbing, colour change or systemic symptoms requires prompt device removal by an appropriate clinician and full inspection.
Falls, inability to transfer safely, contralateral foot injury or a major leg-length discrepancy can make an otherwise effective device unsafe without modification.
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.
Investigation priorities
Detect infection, ischaemia, deep tissue involvement and heavy exudate that change device choice or demand urgent referral.
Management branches
A neuropathic plantar ulcer is uninfected, non-ischaemic and suitable for knee-high device treatment.
- Offer 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.
- Provide 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.
Mild complications need closer surveillance, or moderate to severe infection, ischaemia or heavy exudate requires frequent access.