Offloading Diabetic Foot Ulcers Q&A

  • Jayesh B. Shah, MD, CWSP, UHM
  • Volume 07 - Issue 1

In anticipation of the publication and current presales of the Wound Care Certification Study Guide, Second Edition, we offer a sneak peek of several questions and answers from“Chapter 20: Offloading Diabetic Foot Ulcers – Orthotics” by Elias R. Cheleuitte, DPM, FACFAS.


1. Which is a common etiology of diabetic foot ulcerations?

         a.) repetitive microtrauma

         b.) peripheral neuropathy

         c.) areas of high pressure

         d.) all of the above

2. Which modality is best suited for forefoot plantar diabetic ulceration?

         a.) healing sandal

         b.) cam walker

         c.) integrated prosthetic and orthotic system (IPOS)

         d.) PO shoe

3. Which is the highest risk factor for diabetic foot ulceration?

         a.) poor glycemic control

         b.) increased plantar pressure

         c.) loss of plantar sensation

         d.) PVD

4. Which modality is considered the gold standard in offloading diabetic foot ulcerations?

         a.) total contact cast

         b.) healing sandal

         c.) CROW device

         d.) PO shoe

5. All of the following factors require consideration before choosing an offloading modality except:

         a.) location of ulceration

         b.) patient functional capabilities

         c.) patient insulin dependency

         d.) vascular studies


  1. d) A common etiology of diabetic foot ulcerations is usually repetitive microtrauma at areas of high pressure in patients with peripheral neuropathy.
  2. c) An integrated prosthetic and orthotic system (IPOS) is best suited to offload diabetic forefoot ulceration. The healing sandal and cam walker are also used to offload diabetic ulcers; however, IPOS is best suited for offloading diabetic forefoot ulcers. The PO shoe is not able to offload forefoot ulcers.
  3. c) Loss of protective sensation in the plantar foot (neuropathy) is the highest risk factor for the diabetic foot ulcer.
  4. a) Total contact casting (TCC) is considered the gold standard for offloading diabetic foot ulcers.
  5. c) Before choosing an offloading device, it is important to look at the location of the ulcer, the functional capabilities of the patient, and the patient’s vascular status. Insulin dependency is not a factor in the choice of an offloading device. 


  1. Bosker GW, La Fontaine J. Orthotics and prosthetics in wound care. Sheffield PJ, Fife CE, editors. Wound Care Practice. 2nd ed. North Palm Beach, Fla.: Best Publishing Company; 2007:901-20.
  2. Armstrong DG, Lavery LA. Elevated peak plantar pressures in patients who have Charcot arthropathy. J Bone Joint Surg Am. 1998 Mar; 80(3):365-9.
  3. Lavery LA, Vela SA, Lavery DC, Quebedeaux TL. Reducing dynamic foot pressures in high-risk diabetic subjects with foot ulcerations. A comparison of treatments. Diabetes Care. 1996; 19(8):818-21.
  4. Reiber GE, Vileikyte L, Boyko EJ, et al. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care. 1999; 22(1):157-62.
  5. Bauman JH, Girling Brand Plantar pressures and trophic ulceration: an evaluation of J Bone Joint Surg. 1963;45B(4):652-73.
  6. Cavanagh PR, Bus SA. Offloading the diabetic footfor ulcer prevention and healing. J Am Podiatr Med Assoc. 2010;52(3Suppl):37S-43S.
  7. Landsman AS, Meaney Cargill RS, et al. Highstrain rate tissue deformation: a theory on the mechanical etiology of diabetic foot ulcerations. J Am Podiatr Med Assoc. 1995;85(10):519-27.
  8. Zou Mueller Lott Effect of peak pressureand pressure gradient on subsurface shear stresses in the neuropathic foot. J Biomech. 2007;40(4):883-90.
  9. Pound N, Chipchase S, Treece K, et al. Ulcer-free survival following management of foot ulcers in diabetes. Diabet Med. 2005; 22(10):1306-9.
  10. Snyder Kirsner RS, RA, et al. Consensus recommendations of advancing the standard of care for treating neuropathic foot ulcers in patients withdiabetes. Ostomy Wound Manage. 2010;56(4Suppl):S1-24.
  11. Van Deursen R. Footwear for the neuropathic patient: offloading and stability. Diabetes Metab Res Rev. 2008; 24(Suppl1):S96-100.
  12. Armstrong DG, Lavery LA, Kimbriel HR, Nixon Boulton Activity patterns of patients with diabetic foot ulceration. Patients with active ulcerations may not adhere to a standard pressure offloading regiment. Diabetes Care. 2003;26(9):2595-97.
  13. Searle A, Campbell R, Fitzgerald A, K. A qualitative approach to understanding the experience of ulceration and healing in the diabetic foot: patient and podiatrist perspective. Wounds. 2005;17(1):16-26.
  14. Crews Armstrong DG, Boulton A method for assessing offloading compliance. JAPMA. 2009; 99(1):100-3.
  15. Wunderlich RP. Off-loading diabetic foot wounds/ orthotics. Shah JB, Sheffield PJ, Fife CE, eds. Wound Care Certification Study Guide. North Palm Beach, Fla.: Best Publishing Company; 2007:163-7.
  16. Snyder Frykberg RG, Rogers LC, Applewhite Bell Bohn G, Fife CE, Jensen Wilcox,management of diabetic foot ulcers through optimal off-loading; building consensus guidelines and practical recommendations to improve outcomes. J Am Podiatr Med Assoc. 2014; 104(6):555-67.
  17. Elias C, DPM. Offloading diabetic foot wounds/ orthotics. Shah JB, Sheffield PJ, Fife CE, eds, Wound Care Certification Study Guide, North Palm Beach, Fla: Best Publishing Company; 2016.

About the Author


JAYESH B. SHAH, MD, CWSP, UHM, is president of South Texas Wound Associates, PA, and of TIMEO2 Healing Concepts, LLC, both in San Antonio, Texas. His degrees include an MBBS (bachelor of medicine and surgery) from Maharaja Sayajirao University in Baroda, India, and an MD in internal medicine from St. Luke’s Roosevelt Hospital, Columbia University, New York. He is board certified in internal medicine and in undersea and hyperbaric medicine and certified in wound management and in hyperbaric medicine.

Shah has more than 18 years’ experience in wound care and hyperbaric medicine practice and more than 12 years’ experience as program director for continuing medical education courses. He currently serves as the medical director for the Northeast Baptist Wound Healing Center. An adjunct professor in the Department of Family and Community Medicine at the University of Texas Health Science Center, Shah is coeditor of the Wound Care Certification Study Guide, First Edition (published by Best Publishing Company). He created the WoundDoctor app for smartphones and authored 19 chapters on various wound topics in four books in addition to more than 30 scientific articles on wound care and hyperbaric medicine.



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