Pressure and off-loading
Is the load coming off the foot?
Off-loading is the most important single treatment for a neuropathic plantar ulcer. Choose the highest step on the ladder the person can safely use.
Draft for clinical review. This page summarises published guidance in plain language. It is a teaching aid and does not replace clinical judgement or your local policies and pathways.
The off-loading hierarchy
For a neuropathic plantar forefoot or midfoot ulcer, guidance (IWGDF 2023) sets out a stepped choice. Start at step 1. Move down only when the device is contraindicated or the person cannot accept it, and record why.
-
Gold standard · non-removable
Non-removable knee-high device
A total contact cast, or a removable walker made non-removable (for example with cast tape or a tie wrap). Either is acceptable first-line; choose by local resources and the person's circumstances.
The person cannot take it off, so non-adherence is designed out. It heals more ulcers than removable options and carries fewer infections and amputations in the evidence.
-
Removable · worn at all times
Removable knee-high device
Use when a non-removable device is contraindicated (for example a heavily exuding wound, or moderate or worse infection) or is not acceptable to the person.
Adherence is the main risk. Explain clearly that it must be worn whenever they are on their feet.
-
Removable · ankle-high
Removable ankle-high device or healing sandal
Where a knee-high device cannot be used or tolerated.
-
Last resort
Felted foam with suitable footwear
Only where no device is available or appropriate. Felt alone, without footwear, is not enough, and compressed felt can raise pressure elsewhere.
Check before you choose
- Perfusion: if ischaemia is suspected, arrange vascular assessment before any non-removable cast. See Vascular.
- Infection: untreated or unresolving infection, or osteomyelitis, rules out a non-removable device. Mild infection or mild ischaemia no longer automatically does.
- Site: this ladder is for plantar forefoot and midfoot ulcers. Heel and non-plantar ulcers have different recommendations in the full guideline.
- Person: work, driving, falls risk, anxiety about casts, and who can attend weekly review.
If you cannot offer the first choice today, start the best available device now and refer for casting. Do not send the person away in the footwear that caused the ulcer.
How devices reduce load
- Load redistribution: contact over the whole sole spreads force over a larger area, so pressure falls.
- Load sharing: the cast wall and shank take part of the load up the leg, away from the forefoot.
- Axial off-loading: reducing the load directly down the leg, for example with a rocker or rigid sole.
Pressure is reduced by redistribution, not removed. Always ask where the load goes instead.
Total contact casting (TCC)
A total contact cast is a minimally padded, knee-high, moulded cast that keeps contact with the whole sole and lower leg. It locks the heel and toes in place, which cuts shear and friction on a fragile wound bed.
Watch: Cast Apply Correct
“Cast Apply Correct” was created by NCA and Andy Gorman. Watch on YouTube if the video does not load.
Who is it for?
Consider TCC
- Neuropathic plantar forefoot or midfoot ulcer
- Non-ischaemic, or mildly ischaemic after vascular assessment
- Uninfected, or mild infection under review
- Can attend regular recasting and understands the cast
Usually not suitable
- Severe peripheral arterial disease
- Untreated osteomyelitis or infection
- Extensive necrosis, or exposed tendon, joint or bone
- Heavy exudate needing daily dressings
- Cannot engage with review, or marked cast anxiety
Competence
Only apply a cast if you have been trained and assessed as competent. Complete the local casting training first, and have a way for the person to get the cast removed urgently.
A simple pathway
- Referral to the multidisciplinary foot service. Aim to be seen within 72 hours.
- Assess: perfusion, infection, wound, and the person's circumstances.
- Neuropathic ulcer suitable: cast applied, ideally the same day.
- Weekly review and recasting until healed, supporting self-management.
- After healing: step down to protective footwear and insoles if needed.
Talking it through
A cast that can be removed usually will be. Explain the benefit and the risks, and agree a plan together. Common worries have practical answers:
| Concern | What helps |
|---|---|
| Cannot drive or work | Plan transport and work in advance; consider a walker as a bridge |
| Fear of falling, daily tasks | Offer a walking aid and a cast protector for the shower |
| Cast slips as swelling settles | Review early and recast |
| Rubbing or new sores | Daily checks for swelling, strike-through, pain or smell, and a number to call |
| Anxiety about the cast | Show a demonstration cast, explain the plan, involve peers, offer support |
| Wet cast | Cast protector, and a pillow between the legs at night to protect the other leg |
The person should return for removal if there is major swelling, heavy exudate, severe pain, a rise in blood glucose, or feeling unwell. They must not remove it themselves.
More training
Further training on total contact casting is available through your local casting course. A link to the NCA learning module will be added once confirmed.
Sources
- Bus SA, Armstrong DG, Crews RT, et al. Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev 2024.
- Fletcher J (Chair) et al. Improving offloading for the foot in diabetes: use of total contact casting in practice. Consensus document. Wounds UK and The Diabetic Foot Journal, London, 2024. Summarised here in the author's own words.
- NICE. Diabetic foot problems: prevention and management (NG19), 2019.
- Video: “Cast Apply Correct”, created by NCA and Andy Gorman.