Mechanical pressure is one of the central drivers of diabetic foot ulceration. In a foot that has lost protective sensation to peripheral neuropathy, repetitive stress over a bony prominence produces tissue breakdown that the patient may never feel. Relieving that pressure — a practice known as offloading — is widely regarded as the single most influential intervention in healing plantar diabetic foot ulcers. The 2023 update of the International Working Group on the Diabetic Foot (IWGDF) guideline describes offloading of mechanical tissue stress as “arguably the most important” of the many interventions required to heal these wounds (Bus et al., 2023). This article reviews what current evidence says about how offloading works, which devices perform best, why adherence matters, and how pressure relief extends into ulcer prevention.
Why Offloading Determines Healing
A neuropathic plantar ulcer forms where load concentrates during walking, typically under the metatarsal heads or midfoot. Because the wound sits directly beneath the weight-bearing surface, each step reintroduces the very force that caused the ulcer, disrupting the fragile granulation tissue and delaying closure. Effective wound care, debridement, and infection control all contribute to healing, but without redistributing plantar pressure away from the wound, these measures often stall. The clinical goal is to transfer load to other regions of the foot and lower leg so the ulcer bed can remain undisturbed long enough to repair (Dinh, 2025).
The Evidence for Non-Removable Knee-High Devices
Across systematic reviews and meta-analyses, non-removable knee-high devices consistently produce the highest healing rates. The IWGDF 2023 guideline recommends a non-removable knee-high offloading device — a total contact cast (TCC) or a knee-high walker rendered irremovable — as the first-choice intervention for a neuropathic plantar forefoot or midfoot ulcer (Bus et al., 2023). These devices distribute pressure over a large surface area and, critically, cannot be taken off by the patient between clinic visits.
The importance of that last point is illustrated by studies comparing casts with removable boots. In a secondary analysis of step activity, patients treated with total contact casts healed 93% of ulcers at an average of 77 days, whereas those in removable cast walkers healed only 65% of ulcers and took an average of 138 days when healing occurred. Step counts and walking cadence were higher in the removable-device group, suggesting that the ability to remove the boot translated into more loading of the wound (Wendland et al., 2023). The device that limits activity and cannot be removed tends to win.
Balancing Effectiveness With Practical Constraints
Despite their strong performance, non-removable devices are not always appropriate. They limit inspection of the foot, which is a concern in patients with peripheral arterial disease or active infection, and some patients cannot tolerate a rigid cast. The IWGDF guideline accordingly offers a stepped pathway: when contraindications or intolerance exist, a removable knee-high or ankle-high device is the second choice, and appropriately fitting footwear combined with felted foam is the third choice when no device is available (Bus et al., 2023).
Clinicians have also developed hybrid solutions to preserve the healing advantage of casting while allowing wound access. One approach uses total contact casts with a ventral window, which permits inspection and dressing changes while maintaining irremovable offloading. In a retrospective comparison, this design was associated with a markedly shorter time to remission than removable casts and was used safely even in patients with peripheral arterial disease (Hochlenert & Fischer, 2022). Such adaptations reflect an ongoing effort to reconcile biomechanical effectiveness with the realities of monitoring a high-risk foot.
From Healing to Prevention
Offloading does not end when the ulcer closes. Newly healed skin remains vulnerable, and recurrence rates are high. Once an ulcer has healed, custom orthoses and appropriately designed therapeutic footwear become essential to keep peak plantar pressures low and reduce the likelihood that the wound returns (Dinh, 2025). Guideline authors emphasize that the same principle — controlling mechanical load — underpins both healing and long-term prevention, and that consistent use of pressure-relieving footwear is a cornerstone of protecting the at-risk foot over time (Bus & Lazzarini, 2024).
Key Takeaways
Current evidence supports a clear hierarchy in the offloading of neuropathic plantar diabetic foot ulcers. Non-removable knee-high devices, particularly total contact casts, deliver the fastest and most reliable healing, largely because they enforce pressure relief that patients cannot circumvent. Removable devices and footwear-based strategies remain valuable when casting is contraindicated or not tolerated, but their effectiveness depends heavily on consistent use. After healing, therapeutic footwear and custom orthoses carry the work of pressure redistribution forward to prevent recurrence. Understanding these principles helps patients, caregivers, and clinicians appreciate why offloading is treated as the foundation of diabetic foot ulcer care.
References
Bus, S. A., Armstrong, D. G., Crews, R. T., Gooday, C., Jarl, G., Kirketerp-Møller, K., Viswanathan, V., & Lazzarini, P. A. (2023). Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews, 40(3), e3647.
Bus, S. A., & Lazzarini, P. A. (2024). The Why, What and Where Podcast on the Updated 2023 IWGDF Guideline on Offloading Treatments for Diabetes-Related Foot Ulcers. Diabetes Therapy.
Dinh, T. L. (2025). Nonsurgical Offloading of the Diabetic Foot. Clinics in Podiatric Medicine and Surgery, 42(4), 647–656.
Hochlenert, D., & Fischer, C. (2022). Ventral Windowed Total Contact Casts Safely Offload Diabetic Feet and Allow Access to the Foot. Journal of Diabetes Science and Technology, 16(1), 137–143.
Wendland, D. M., Kline, P. W., Bohnert, K. L., Biven, T. M., & Sinacore, D. R. (2023). Offloading of Diabetic Neuropathic Plantar Ulcers: Secondary Analysis of Step Activity and Ulcer Healing. Advances in Skin & Wound Care, 36(4), 194–200.
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