Plantar diabetic foot ulcers are among the most stubborn wounds in clinical practice, and the single most important factor that decides whether they heal is rarely a dressing or a drug. It is offloading — the redistribution of mechanical pressure away from the wound. The 2023 update to the International Working Group on the Diabetic Foot (IWGDF) guideline on offloading reaffirms what biomechanical and clinical evidence has shown for decades: relieving pressure is the cornerstone of healing for neuropathic plantar ulcers, and the type of device used matters enormously.
Why Pressure Drives Diabetic Foot Ulcer Outcomes
In a foot with peripheral neuropathy, repetitive plantar pressure and shear stress accumulated during weight-bearing activity are the primary mechanical drivers of tissue breakdown and delayed healing. Once an ulcer has formed, every additional step concentrates force on a wound bed that cannot be felt and cannot rest. As Bus and colleagues summarized in the IWGDF 2023 update, an unoffloaded plantar wound is essentially a wound that is being re-injured continuously. Offloading interrupts that cycle by spreading load across a larger surface area, modifying gait, and limiting cumulative mechanical stress, allowing tissue perfusion and granulation to proceed.
Peak plantar pressure reductions of up to roughly 87% in the forefoot have been demonstrated with well-applied non-removable devices compared with conventional footwear (Snyder et al., 2016).
The 2023 IWGDF Hierarchy of Offloading
The 2023 IWGDF guideline, developed using the GRADE framework, sets out a clear hierarchy for treating a neuropathic plantar forefoot or midfoot ulcer (Bus et al., 2024).
First choice: a non-removable knee-high device
The preferred intervention is a non-removable knee-high offloading device — either a total contact cast (TCC) or a removable walker rendered irremovable by the clinician. Non-removability is essential because it eliminates the variable that most often undermines healing in real-world practice: inconsistent wear.
Second choice: a removable knee-high or ankle-high device
If a non-removable device is contraindicated — for example, in the presence of significant ischemia, active infection, fluctuating edema, or patient intolerance — a removable knee-high or, failing that, ankle-high walker is recommended. These devices can offload as effectively as a TCC under laboratory conditions but require disciplined wear to translate into healing.
Third choice and surgical options
Where no offloading device is available, appropriately fitting therapeutic footwear combined with felted foam padding becomes the fallback. The guideline frames this as a last resort. For plantar forefoot ulcers that fail to heal with optimal mechanical offloading, the guideline endorses considering surgical procedures such as Achilles tendon lengthening, metatarsal head resection, joint arthroplasty, or metatarsal osteotomy.
What the Comparative Evidence Shows
A 2023 systematic review and meta-analysis by Chen and colleagues in Frontiers in Endocrinology pooled twelve studies and 591 patients comparing TCCs with removable walkers or footwear. The TCC group had higher healing rates (risk ratio 1.22; 95% CI 1.11–1.34; p<0.001) and shorter time to healing (standardized mean difference -0.57; 95% CI -1.01 to -0.13; p=0.010). Device-related complications were more common with TCCs than with footwear but did not differ significantly from those seen with removable walkers.
The Adherence Problem
The strongest argument for non-removable devices is not their offloading capacity in a gait lab — it is human behavior. Crews and colleagues (Diabetes Care, 2016) found that patients wore their removable cast walker for only about 28% of weight-bearing activity, and adherence was a strong independent predictor of healing.
More recent work by Jarl and colleagues (2022) reported a median self-reported adherence of 90% of daily steps, while objective dual-activity monitoring showed only 35% — a striking gap between perception and reality. Male sex, longer diabetes duration, absence of peripheral arterial disease, and perceived device weight were all associated with lower adherence. These findings reinforce why the IWGDF treats enforced adherence as a clinical feature, not a paternalistic one.
Clinical Takeaways
For a neuropathic plantar forefoot or midfoot ulcer, current evidence supports a non-removable knee-high device as first-line care, with TCC retaining its position as the gold standard. Removable walkers offload as well in principle but underperform in practice because patients do not wear them enough. When non-surgical offloading fails, surgical options exist and should be considered before the wound becomes chronic. Across every device choice, the underlying principle is unchanged: wounds heal when the mechanical insult that created them is removed.
References
- Bus SA, Armstrong DG, Crews RT, et al. Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3647.
- Schaper NC, van Netten JJ, Apelqvist J, et al. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3657.
- Chen L, Sun S, Gao Y, Ran X. Total contact casts versus removable offloading interventions for the treatment of diabetic foot ulcers: a systematic review and meta-analysis. Frontiers in Endocrinology. 2023;14:1234761.
- Crews RT, Shen BJ, Campbell L, et al. Role and determinants of adherence to off-loading in diabetic foot ulcer healing: a prospective investigation. Diabetes Care. 2016;39(8):1371–1377.
- Jarl G, van Netten JJ, Lazzarini PA, et al. Factors associated with adherence to using removable cast walker treatment among patients with diabetes-related foot ulcers. BMJ Open Diabetes Research & Care. 2022;10(1):e002551.
- Snyder RJ, Frykberg RG, Rogers LC, et al. The role of pressure offloading on diabetic foot ulcer healing and prevention of recurrence. Plastic and Reconstructive Surgery. 2016;138(3 Suppl):179S–187S.
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