Offloading—the redistribution of mechanical pressure away from an ulcerated area of the foot—is widely regarded as the single most important intervention for healing a neuropathic plantar foot ulcer in a person with diabetes. Repetitive pressure and shear on an insensate foot both cause these wounds and prevent them from closing. Yet despite decades of high-quality evidence, the most effective offloading methods remain underused in everyday practice. This article reviews what the peer-reviewed literature and international guidelines say about how, and why, to take the load off a diabetic foot ulcer.
Why Pressure, Not Just the Wound, Must Be Treated
In a foot affected by diabetic peripheral neuropathy, the protective sensation that normally prompts a person to shift their weight or stop walking is diminished or absent. As a result, ordinary walking delivers repeated, unfelt trauma directly to the wound bed. According to PubMed, the International Working Group on the Diabetic Foot (IWGDF) describes offloading as “arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer” (Bus et al., 2020; Bus et al., 2023). No amount of advanced dressing, debridement, or topical therapy can fully compensate if the underlying mechanical stress continues unabated. This reframes the clinical problem: the ulcer is a symptom of abnormal loading, and durable healing depends on correcting that loading.
The Evidence for Non-Removable Knee-High Devices
The strongest evidence supports non-removable, knee-high offloading devices—the total contact cast (TCC) and non-removable walkers. In the 2023 update of its offloading guideline, the IWGDF recommends a non-removable knee-high device as the first-choice intervention for a neuropathic plantar forefoot or midfoot ulcer (Bus et al., 2023). These devices heal ulcers faster and at higher rates than removable alternatives, largely because they cannot be taken off. A French clinical review noted that neuropathic ulcers treated with a cast heal in an average of roughly six weeks with a high level of evidence (Ha Van, 2019).
The key mechanism is adherence. A removable device only works while it is being worn, and studies consistently show that patients wear removable devices for a minority of their steps. Non-removable devices remove that decision, ensuring the foot is protected during every step of the day. This is why guideline authors rank an irremovable device above a removable one even when the two are biomechanically similar.
Practical Barriers and Newer Cast Designs
Despite this evidence, total contact casting remains underused worldwide. Casts conceal the foot from inspection, are relatively contraindicated in significant peripheral arterial disease or infection, and can be inconvenient for bathing, sleep, and transportation. To address these limitations, clinicians have explored modified designs. One retrospective study described a ventral-windowed TCC that allows access to the wound for inspection and care while preserving the offloading benefits of an irremovable cast; complications were uncommon and did not limit its use even in patients with peripheral arterial disease (Hochlenert & Fischer, 2020). Separately, a comparison of a non-removable total contact softcast against a conventional TCC found similar healing rates and a potentially shorter healing time with the softcast, suggesting lighter, better-tolerated casts may achieve comparable results (Vierhout et al., 2022).
A Stepwise Clinical Pathway
Current guidance frames offloading as a hierarchy. When a non-removable knee-high device is contraindicated or not tolerated, a removable knee-high device is the second choice, followed by a removable ankle-high device. Only when no offloading device is available should appropriately fitting footwear combined with felted foam be used, and it is considered a later-line option (Bus et al., 2023). When non-surgical offloading fails to heal a plantar forefoot ulcer, surgical offloading—such as Achilles tendon lengthening, metatarsal head resection, or a flexor tendon tenotomy for a toe ulcer—may be considered. Ulcers complicated by infection or ischaemia, and non-plantar or heel ulcers, require individualized modifications to this pathway. Importantly, national guidelines vary widely in how closely they follow these international recommendations; one comparative study found offloading to be the chapter where national guidelines diverged most from IWGDF guidance (Parker et al., 2019).
Key Takeaways
Offloading mechanical stress is central to healing diabetic foot ulcers, not an optional adjunct to wound care. The evidence favors non-removable, knee-high devices as first-line treatment because they guarantee adherence throughout the walking day. Practical barriers to total contact casting are real but increasingly addressable through windowed and softcast designs. A structured, stepwise approach—escalating from non-removable devices to removable devices, accommodative footwear, and, when needed, surgical offloading—offers the best chance of closing these wounds and reducing the downstream risks of infection, hospitalization, and amputation. The persistent gap between this evidence and routine clinical practice remains one of the most consequential, and most correctable, problems in diabetic foot care.
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.
Bus SA, Armstrong DG, Gooday C, et al. Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes/Metabolism Research and Reviews. 2020;36(S1):e3274.
Vierhout BP, Visser R, Hutting KH, et al. Comparing a non-removable total contact cast with a non-removable softcast in diabetic foot ulcers: A retrospective study of a prospective database. Diabetes Research and Clinical Practice. 2022;191:110036.
Hochlenert D, Fischer C. Ventral windowed total contact casts safely offload diabetic feet and allow access to the foot. Journal of Diabetes Science and Technology. 2022;16(1):137–143.
Ha Van G. Why and how to off-load a diabetic foot ulcer? La Revue du Praticien. 2019;69(6):616–619.
Parker CN, Van Netten JJ, Parker TJ, et al. Differences between national and international guidelines for the management of diabetic foot disease. Diabetes/Metabolism Research and Reviews. 2019;35(2):e3101.
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