Bakker K., Apelqvist J., Schaper N.C. (On behalf of the International Working Group on the Diabetic Foot). Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes, Metab Res Rev. 2012; 28:225-231

Caravaggi C., Faglia E., De Giglio R. Effectiveness and safety of a nonremovable fiberglass off-bearing cast versus a therapeutic shoe in the treatment of neuropathic foot ulcers: a randomized study. Diabetes Care. 2000; 23:(12)1746-1751

Armstrong D.G., Nguyen H.C., Lavery L.A. Off-loading the diabetic foot wound: a randomized control trial. Diabetes Care. 2001; 24:(6)1019-1022

Reiber G.E., Smith D.G., Wallace C. Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. J American Medical Association. 2002; 287:(19)2552-2558

Van Deursen R. Mechanical loading and off-loading of the plantar surface of the diabetic foot. Clin Infect Dis. 2004; 39:S87-S91

Piaggesi A., Macchiarini S., Rizzo L. An off-the-shelf instant contact casting device for the management of diabetic foot ulcers: a randomized prospective trial versus traditional fibreglass cast. Diabetes Care. 2007; 30:(3)586-590

Faglia E., Caravaggi C., Clerici G. Effectiveness of removable walker cast versus nonremovable fiberglass off-bearing cast in the healing of diabetic plantar foot ulcer: a randomized controlled trial. Diabetes Care. 2010; 33:(7)1419-1423

Boulton A.J. Pressure and the diabetic foot: clinical science and offloading techniques. Am J Surg. 2004; 187:(5A)17S-24S

Burden A.C., Jones G.R., Jones R., Blandford R.L. Use of the “Scotchcast boot” in treating diabetic foot ulcers. Br Med J.(Clin Res Ed). 1983; 286:(6377)1555-1557

Cavanagh P.R., Ulbrecht J.S., Caputo G.M. New developments in the biomechanics of the diabetic foot. Diabetes Metab Res Rev. 2000; 16:S6-S10

Cavanagh P.R., Lipsky B.A., Bradbury A.W., Botek G. Treatment for diabetic foot ulcers. Lancet. 2005; 366:(9498)1725-1735

Leung P.C. Diabetic foot ulcers – a comprehensive review. Surgeon. 2007; 5:(4)219-231

Edmonds M.E., Foster A.V.M., Sanders L.J. A Practical Manual of Diabetic Footcare.: Blackwell Publishing; 2008

Armstrong D.G., Lavery L.A., Wu S., Boulton A.J. Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds: a randomized controlled trial. Diabetes Care. 2005; 28:(3)551-554

Katz I.A., Harlan A., Miranda-Palma B. A randomized trial of two Irremovable off-loading devices in the management of plantar neurophatic foot ulcers. Diabetes Care. 2005; 28:(3)555-559

Spencer S. Pressure relieving interventions for preventing and treating diabetic foot ulcers. Cochrane Database Syst Rev. 2000; 3:1-21

Jeffcoate W.J., Harding K.G. Diabetic Foot Ulcers. Lancet. 2003; 361:(9368)1545-1551

Beuker B.J., van Deursen R.W., Price P. Plantar pressure in off-loading devices used in diabetic ulcer treatment. Wound Repair Regen. 2005; 13:(6)537-542

Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). 2011. (Accessed February 2013)

The Cochrane Collaboration. RevMan 5.2 Tool. 2013. (accessed February 2013)

EBL Critical Appraisal Check-list. (accessed March 2013)

Mueller M.J., Diamond J.E., Sinacore D.R. Total contact casting in treatment of diabetic plantar ulcers: controlled clinical trial. Diabetes Care. 1989; 12:(6)384-388

Zimny S., Schatz H., Pfohl U. The effects of applied felted foam on wound healing and healing times in the therapy of neuropathic diabetic foot ulcers. Diabetic Medicine. 2003; 20:(8)622-625

Van de Weg F.B., Van der Windt D.A., Vahl A.C. Wound healing: total contact cast vs. custom-made temporary footwear for patients with diabetic foot ulceration. Prosthet Orthot Int. 2008; 32:(1)3-11

Mason J., O’Keeffe C., McIntosh A. A systematic review of foot ulcer in patients with type 2 diabetes mellitus. I: prevention. Diabet Med. 1999; 16:(10)801-812

Bus S.A., van Deursen R.W., Armstrong D.G. 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:S162-S180

Dumont I.J., Lepeut M.S., Tsirtsikolou D.M. A proof-of-concept study of the effectiveness of a removable device for offloading in patients with neuropathic ulceration of the foot: the Ransart boot. Diabet Med. 2009; 26:(8)778-782

Birke J.A., Pavich M.A., Patout C.A., Horswell R. Comparison of forefoot ulcer healing using alternative off-loading methods in patients with diabetes mellitus. Adv Skin Wound Care. 2002; 15:(5)210-215

Nabuurs-Franssen M.H., Sleegers R., Huijberts M.S. Total contact casting of the diabetic foot in daily practice: a prospective follow-up study. Diabetes Care. 2005; 28:(2)243-247

Boulton A.J. The diabetic foot: from art to science: the 18th Camillo Golgi lecture. Diabetologia. 2004; 47:(8)1343-1353

Svensson H., Apelqvist J., Larsson J. Minor amputations in patients with diabetes mellitus and severe foot ulcers achieves good outcomes. J Wound Care. 2011; 20:(6)261-274

Schaper N.C., Apelqvist J., Bakker K. Reducing lower leg amputations in diabetes: a challenge for patients, healthcare providers and the healthcare system. Diabetologia. 2012; 55:(7)1869-1872

Department of Health, Dublin. Department of Health Statement of Strategy 2011-2014. 2012. (Accessed August 2015)

Drummond M.F., Sculpher M.J., Torrance G.W. (2005) Methods for the Economic Evaluation of Health Care Programs, 3rd edn. : Oxford University Press; 2005

Conner M., Norman P. Predicting Health Behaviour, 2nd edn. : Open University Press; 2005

Brod M. Quality of life issues in patients and lower extremity ulcers: patients and care givers. Qual Life Res. 1998; 7:(4)365-372

German P.S. Compliance and Chronic Disease. Hypertension. 1988; 11:(3)56-60

Murphy N., Canales M. critical analysis of compliance. Nurs Inq. 2001; 8:(3)173-181

Vileikyte L. Diabetic foot ulcers: a quality of life issue. Diabetes Metab Res Rev. 2001; 17:(4)246-249

Vileikyte L., Rubin R.R., Leventhal H. Psychological aspects of diabetic neuropathic foot complications: an overview. Diabetes Metab Res Rev. 2004; 20:S13-S18

Morona J.K., Buckley E.S., Jones S. Comparison of the clinical effectiveness of different off-loading devices for the treatment of neuropathic foot ulcers in patients with diabetes: a systematic review and meta-analysis. Diabetes Metab Res Rev. 2013; 29:(3)183-193

Agas C.M., Bui T.D., Driver V.R, Gordon I.L. Effect of window casts on healing rates of diabetic foot ulcers. J Wound Care. 2006; 15:(2)80-83

Moore Z. Meta-analysis in context. J Clin Nurs. 2012; 21:19-20

Callcut R.A., Branson R.D. How to read a review paper. Respir Care. 2009; 54:(10)1379-1385

Ried K. Interpreting and understanding meta-analysis graphs: a practical guide. Aust Fam Physician. 2006; 35:(8)635-638

Lewis J., Lipp A. Pressure-relieving interventions for treating diabetic foot ulcers. Cochrane Database Syst Rev. 2013; 31:(1)

Gottrup F., Apelqvist J., Price P. Outcomes in controlled and comparative studies on non-healing wounds: recommendations to improve the quality of evidence in wound management. J Wound Care. 2010; 19:(6)239-268

The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. (accessed March 2013)

Armstrong D.G., Lavery L.A., Wrobel J.S., Vileikyte L. Quality of life in Healing Diabetic Wounds: does the end justify the means?. J Foot Ankle Surg. 2008; 47:(4)278-282

Boulton A.J.M., Bower J.H., Gadia M. Use of plaster casts in the management of diabetic neuropathic foot ulcers. Diabetes Care. 1986; 9:(2)149-152

Caravaggi C., Sganzaroli A., Fabbi M. Nonwindowed, nonremovable fiberglass off-loading cast versus removable pneumatic cast (AircastXP Diabetic Walker) in the treatment of neuropathic noninfected plantar ulcers: a randomised prospective trial. Diabetes Care. 2007; 30:(10)2577-2578

Gutekunst D.J., Hastings M.K., Bohnert K.L. Removable cast walker boots yield forefoot off-loading than total contact casts. Clinical Biomech. 2011; 26:649-654

Ha Van G., Siney H., Hartmann-Heurtier A. Nonremovable, windowed, fiberglass cast boot in the treatment of diabetic plantar ulcers. Diabetes Care. 2003; 26:(10)2848-2852

Holstein P., Larsen K., Sager P. Decompression with the aid of insoles in the treatment of diabetic neuropathic ulcers. Acta Orthop Scand. 1976; 47:(4)463-468

Knowles E.A., Boulton A.J. Do people with diabetes wear their prescribed footwear?. Diabet Med. 1996; 13:(12)1064-1068

Laing P., Cogley D.I., Klenerman L. Neuropathic foot ulceration treated by-total contact casts. J Bone Joint Surg Br. 1991; 74:(1)133-136

Myerson M., Papa J., Eaton K., Wilson K. The total contact cast for management of neuropathic plantar ulceration of the foot. J Bone Joint Surg Am. 1992; 74:(2)261-269

Saltzman C.L., Zimmerman M.B., Holdsworth R.L. Effect of initial weight-bearing in a total contact cast on healing of diabetic foot ulcers. J Bone Joint Surg Am. 2004; 86A:(12)2714-2719

Treatment of the diabetic foot by offloading: a systematic review

02 December 2022
Volume 6 · Issue 4



To compare the literature on the strengths and limitations of different offloading devices in the treatment of diabetic foot ulcers.


Systematic review of the literature in the following databases: the Cumulative Index to Nursing an Allied Health Literature (CINAHL); Medline; Embase; Cochrane Library and Web of Knowledge. The search strategy used the terms: diabetic foot; orthosis/orthotic devices/orthoses; foot orthosis/foot orthoses; casts/plaster cast/surgical cast; shoes.


Our results identified 15 studies, which are included in this review. Healing rates, healing times and reduction in ulcer size were improved with the use of total contact casting, when compared with other offloading devices. The main adverse effects associated with the use of the device were infection, maceration and abrasion. Cost, compliance and quality of life issues were rarely included within the studies.


Offloading is a key treatment strategy for the management of diabetic foot ulcers and total contact casts were found to be the most effective devices to achieve ulcer healing. However, they are not without complications and their impact on cost, compliance and quality of life is not well understood.

Pressure plays a central role in the development of diabetic foot ulcers (DFU) and its management becomes essential, not only to prevent the development of new ulcers but also to allow the healing process to take place.1,2,3,4,5,6,7 Pressure results from mechanical loading of the feet when the individual engages in activities such as walking and standing, exposing the plantar surface of the feet to reaction forces that act upon the foot tissue, causing compression and sometimes shear stress.5 This pressure and stress is aggravated by foot deformities such as hammer and claw toes, prominence of metatarsal heads, hallux valgus and limited joint mobility.1,5,8 For these reasons, offloading the foot and accommodating its deformities with the use of appropriate footwear is essential for the prevention and treatment of DFUs.5

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