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Podiatrists urged to use proven therapies to heal diabetic foot ulcers

Midwest Podiatry Conference
Midwest Podiatry Conference
  • Midwest Podiatry Conference
    Midwest Podiatry Conference
    Midwest Podiatry Conference
    Midwest Podiatry Conference

Chicago—Diabetic patients with foot ulcers that have not begun healing in six to eight weeks should ask their podiatrist if a new approach to caring for the ulcer is warranted, according to a California podiatrist presenting data at the Midwest Podiatry Conference.

Douglas H. Richie Jr., D.P.M., is associate clinical professor, Department of Applied Biomechanics at California School of Podiatric Medicine.  He presented his findings at the Midwest Podiatry Conference in Chicago on Thursday, April 19th.

Patients with diabetes often suffer from neuropathy, which is a nerve condition that prevents feeling in the feet.  This numbness masks sores that an otherwise healthy patient would detect.  Left untreated, these sores or ulcers can lead to amputations.

Despite recent success at lowering amputation rates, podiatrists face a tough challenge to prevent ulcers from reaching this more drastic phase.  However, in the last decade doctors have developed a number of therapies to help these ulcers heal, called off-loading.

According to Richie, off loading is the mechancial intervention to prevent pressure or stress on the foot while an ulcer is being treated.  Typically, off-loading is created with a boot or cast the patient wears until healing occurs.

Richie said the problem arises when podiatrists and other physicians prescribe a removable boot.

Recently, efforts have been made by the International Working Group on the Diabetic Foot to develop specific evidence-based guidelines on the use of footwear and off-loading for ulcer prevention and healing in the diabetic foot.

The group developed four recommendations doctors should follow, and patients should ask about:

1. Relieving pressure on ulcers should always be a part of a plan to treat diabetic foot ulcers.

2. Total contact casts and non-removable walkers are the preferred interventions

3. Forefoot off-loading shoes or cast shoes may be used when above-the-ankle devices are not appropriate or not tolerated by the patient.

4. Conventional or standard therapeutic footwear should not be used because many other devices are more effective.

Richie said studies and surveys of podiatrists have found that only between 2 and 11 percent of podiatrist use the proper non removable cast to effectively off load ulcers, despite the strong evidence that non removable contact casts are very effective at healing ulcers.

He said the reasons for this are complex. 

“Podiatrists often prescribe the removable cast because patients prefer them because they can be removed and therefore more comfortable. However, for the ulcer to be effectively off loaded, the cast must stay on continuously, until it is removed and the foot is cleaned and the cast replace, which should occur every week,” he said.

“Podiatrists often prescribe walking boots because patients prefer them over non removable casts.  However, that is the problem.  Patients will remove the casts more often than the allowable period for sleeping or bathing.  In order for an ulcer to be effectively off loaded, the boot or cast must stay on for the entire period of time that the patient is on their feet,” he said.