External Offloading and Immobilisation

  • Dirk Hochlenert
  • Gerald Engels
  • Stephan Morbach
  • Stefanie Schliwa
  • Frances L. Game


Redistribution of load is the most important measure to prevent or to treat diabetic foot ulcers. Redistributing load efficiently means that it is possible to offload the region in question without the need to drastically limit the steps the patient takes. This allows the patient to maintain mobility and to continue the life she or he is used to. Remaining mobile also allows the individual to maintain control of their diabetes and an overall healthy lifestyle.


  1. 1.
    Armstrong DG, Lavery LA, Wu S, Boulton AJ. Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds: a randomized controlled trial. Diabetes Care. 2005;28(3):551–4.CrossRefPubMedGoogle Scholar
  2. 2.
    Lavery LA, Higgins KR, La Fontaine J, Zamorano RG, Constantinides GP, Kim PJ. Randomised clinical trial to compare total contact casts, healing sandals and a shear-reducing removable boot to heal diabetic foot ulcers. Int Wound J. 2015;12(6):710–5. Scholar
  3. 3.
    Wu SC, Jensen JL, Weber AK, Robinson DE, Armstrong DG. Use of pressure offloading devices in diabetic foot ulcers: do we practice what we preach? Diabetes Care. 2008;31(11):2118–9. Scholar
  4. 4.
    NICE. Diabetic foot problems: prevention and management; 2 Research recommendations. 2015. Accessed 27 Mar 2018.
  5. 5.
    Burnett O. Total contact cast. Clin Podiatr Med Surg. 1987;4(2):471–9.PubMedGoogle Scholar
  6. 6.
    Begg L, McLaughlin P, Vicaretti M, Fletcher J, Burns J. Total contact cast wall load in patients with a plantar forefoot ulcer and diabetes. J Foot Ankle Res. 2016;9:2. Scholar
  7. 7.
    Piaggesi A, Macchiarini S, Rizzo L, Palumbo F, Tedeschi A, Nobili LA, Leporati E, Scire V, Teobaldi I, Del Prato S. 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):586–90. Scholar
  8. 8.
    Armstrong DG, Short B, Espensen EH, Abu-Rumman PL, Nixon BP, Boulton AJ. Technique for fabrication of an “instant total-contact cast” for treatment of neuropathic diabetic foot ulcers. J Am Podiatr Med Assoc. 2002;92(7):405–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Katz IA, Harlan A, Miranda-Palma B, Prieto-Sanchez L, Armstrong DG, Bowker JH, Mizel MS, Boulton AJ. A randomized trial of two irremovable off-loading devices in the management of plantar neuropathic diabetic foot ulcers. Diabetes Care. 2005;28(3):555–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Armstrong DG, Lavery LA, Kimbriel HR, Nixon BP, Boulton AJ. Activity patterns of patients with diabetic foot ulceration: patients with active ulceration may not adhere to a standard pressure off-loading regimen. Diabetes Care. 2003;26(9):2595–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Bus SA, van Deursen RW, Armstrong DG, Lewis JE, Caravaggi CF, Cavanagh PR, Foot International Working Group on the Diabetic. Footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review. Diabetes Metab Res Rev. 2016;32(Suppl 1):99–118. Scholar
  12. 12.
    Koller A, Kersken J. Hilfsmittel beim Diabetischen Fußsyndrom. Total Contact Cast und Orthesen. Orthopädie-Technik. 2013;7:1–6.Google Scholar
  13. 13.
    Morbach S, Müller E, Reike H, Risse A, Rümenapf G, Spraul M. Diabetisches Fußsyndrom. Diabetologie und Stoffwechsel. 2009;4(S 02):S157–65. Scholar
  14. 14.
    Bus SA, Valk GD, van Deursen RW, Armstrong DG, Caravaggi C, Hlavacek P, Bakker K, Cavanagh PR. 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(Suppl 1):S162–80. Scholar
  15. 15.
    Armstrong DG, Lavery LA, Bushman TR. Peak foot pressures influence the healing time of diabetic foot ulcers treated with total contact casts. J Rehabil Res Dev. 1998;35(1):1–5.PubMedGoogle Scholar
  16. 16.
    Gutekunst DJ, Hastings MK, Bohnert KL, Strube MJ, Sinacore DR. Removable cast walker boots yield greater forefoot off-loading than total contact casts. Clin Biomech (Bristol, Avon). 2011;26(6):649–54. Scholar
  17. 17.
    Waaijman R, Keukenkamp R, de Haart M, Polomski WP, Nollet F, Bus SA. Adherence to wearing prescription custom-made footwear in patients with diabetes at high risk for plantar foot ulceration. Diabetes Care. 2013;36(6):1613–8. Scholar
  18. 18.
    Tovey FI. The manufacture of diabetic footwear. Diabet Med. 1984;1(1):69–71.CrossRefPubMedGoogle Scholar
  19. 19.
    Busch K, Chantelau E. Effectiveness of a new brand of stock ‘diabetic’ shoes to protect against diabetic foot ulcer relapse. A prospective cohort study. Diabet Med. 2003;20(8):665–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Uccioli L, Faglia E, Monticone G, Favales F, Durola L, Aldeghi A, Quarantiello A, Calia P, Menzinger G. Manufactured shoes in the prevention of diabetic foot ulcers. Diabetes Care. 1995;18(10):1376–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Dirk Hochlenert
    • 1
  • Gerald Engels
    • 2
  • Stephan Morbach
    • 3
  • Stefanie Schliwa
    • 4
  • Frances L. Game
    • 5
  1. 1.Amb. Zentrum für DiabetologieEndoskopie & Wundheilung GemeinschaftspraxisKölnGermany
  2. 2.Department of Wound SurgerySt. Vinzenz Hospital and MVZ St. MarienKölnGermany
  3. 3.Department of Diabetes and AngiologyMarienkrankenhaus GmbHSoestGermany
  4. 4.Institute of Anatomy, Anatomy and Cell BiologyUniversity of BonnBonnGermany
  5. 5.Department of Diabetes and EndocrinologyDerby Hospitals NHS Foundation TrustDerbyUK

Personalised recommendations