Standard, Appropriate, and Advanced Care and Medical-Legal Considerations: Part One -- Diabetic Foot Ulcerations

Gerit Mulder, DPM, MS, David Armstrong, DPM, Susie Seaman, MSN, NP, CETN


Wounds. 2003;15(4) 

In This Article


Reduction of pressure, or offloading, is another essential aspect of diabetic wound care. Foot pressures, shock, and shear can be reduced with appropriately fitted shoes, insoles, and socks.[10,40] Total nonweight bearing using a wheelchair or crutches is the most effective method of relieving pressure although most patients have difficulty complying with these modalities. Total contact casts (TCCs) and removal casts are effective in significantly reducing pressure but may cause additional problems when inappropriately applied. TCCs are used for offloading the plantar aspect of the foot. Published studies suggest TCCs heal greater than 72 percent of all patients treated with them.[41] Clinical skill is required for application. Patient compliance is necessary to minimize complications. Inappropriate application may result in a new ulceration. Postural instability may be exacerbated. Contraindications include acute infection ischemia, deep ulcers, and draining wounds.[42] Additional contraindications include ataxic patients and those who are noncompliant, blind, morbidly obese, or have severe peripheral arterial disease.[43] In general, wounds on the posterior heel should not be treated with TCCs.

Pragmatically, removable cast walkers may be preferable to TCCs, as they do not have the same inherent disadvantages. Pressure reduction has been shown to be similar to TCCs with certain types of these devices.[23] Removable walking casts facilitate daily wound inspection and wound care. Infection can be readily detected and complications addressed. Unfortunately, while these devices may seem to be equivalent to TCCs, the fact that they are removable often leads to lapses in adherence to care. Also, patients should not drive automobiles while wearing casts or any offloading device.

Therapeutic footwear is designed primarily for the prevention of ulcer occurrence. A large variety of shoes and ambulatory devices, including but not limited to half shoes and crow walkers, are available for different problems.[40] Shoes should be selected based on the patient's individual needs. When using shoes on patients with diabetic foot ulcers, extra space must be allotted for bulky dressings, which may increase local pressure when in a tightly fitting shoe. Regular assessment of shoes in patients with and without ulcers should be performed to the shoes to ensure the shoes are still appropriate for the patient's needs.

The Medicare-supported Therapeutic Shoe Bill pays for special footwear and insoles. The benefit provides for one pair of custom-molded shoes plus two additional pairs of insoles or one pair of over-the-counter extra-depth shoes plus three pairs of insoles per year. A physician treating the patient must document previous amputation, history of ulcers, pre-ulcer callus, foot deformity, or poor peripheral circulation.[44]

Standard recommendations in the majority of outpatient settings usually consist of a prescription for a post-surgical shoe or over-the-counter athletic shoes. The latter devices are not appropriate for the diabetic foot, as they are not designed to reduce pressure or prevent trauma in the abnormal and insensate foot. Custom-molded shoes and/or inserts are appropriately prescribed for the foot requiring reduction in pressure and repetitive trauma.

It is beyond the scope of this paper to discuss surgical options and approaches for the treatment and prevention of diabetic lower-extremity ulcers. However, when conservative or nonoperative therapy has failed or is not an option, surgical options need to be considered.


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