Offloading boots, braces and protective footwear

What offloading devices do

On a numb foot, pressure builds up with every step, and an ulcer that isn’t protected from it is slow to heal.⁠^[1] Knee-high devices stop just below the knee; ankle-high ones stop just above the ankle or lower. Shoes and inserts are a separate group.⁠^[1]

Swipe sideways to see the whole drawing.

We also apply casts and locked walkers; see total contact casting.

When a removable boot is the right choice

A cast or locked walker isn’t always right. A heavily draining wound, a moderate infection, a job where you can’t wear one, or simply not wanting one are all reasons to choose a removable boot.⁠^[1] A wound that needs frequent checks because of infection or reduced blood flow also suits a removable device. When infection or poor blood flow is severe, treating it comes first; see diabetic foot infection.⁠^[1]

A trial compared three devices in 63 people with diabetes, good circulation and shallow, uninfected ulcers on the sole. Within 12 weeks, 89.5% healed in a total contact cast, 65.0% in a removable cast walker and 58.3% in a half-shoe.⁠^[5] Removable knee-high and ankle-high boots appear to heal about the same share of ulcers; knee-high boots lower pressure more but are worn less.⁠^[1]

We fit offloading boots at the office and show you how to get around safely. At wound visits, usually every week or two, we measure the wound and check the boot.

Wearing it for every step

The hard part is wearing it. Twenty people with diabetic foot ulcers wore one activity monitor at the waist and another on their removable cast walker. The walker was on for only 28% of their daily steps, and even the most consistent wearers had it on for only 60%.⁠^[2] In 79 people with type 2 diabetes and ulcers on the sole, removable devices were worn for 59% of activity on average. Those who wore them more had smaller ulcers at six weeks, and feeling unsteady strongly predicted wearing the device less.⁠^[6]

Habits that help:

• Wear it for all weight-bearing activity, even short walks at home, such as to the bathroom at night.⁠^[1]
• Don’t swap it for a shoe. The guideline advises against using ordinary shoes or off-the-shelf extra-depth shoes in place of a device to heal an ulcer on the sole.⁠^[1]
• Even out your step. A lift in the other shoe may make walking in a thick-soled boot more comfortable and steady. If the boot leaves you unsteady, a cane or walker is worth considering.⁠^[1]

After healing: therapeutic shoes and inserts

After an ulcer on the sole heals, the guideline recommends therapeutic footwear shown to relieve pressure under the foot while walking, worn indoors and outdoors. For a deformity that raises pressure, or a sign that an ulcer may be forming, extra-depth or custom-made shoes, custom insoles or toe orthoses may be prescribed.⁠^[3] A numb foot can’t judge fit, so a trained professional should check it while you stand, ideally late in the day.⁠^[3]

In 107 people with diabetes and a recently healed ulcer on the sole, custom-made shoes were worn for 87% of steps away from home but only 61% at home, where people took more steps. The researchers suggested dedicated protective footwear for indoors.⁠^[7]

We fit therapeutic shoes and custom inserts and check them at your visits. Coverage depends on your plan, and some items need prior authorization. Call 908-215-5953 to inquire about your insurance. Ozturk Foot & Ankle’s page on diabetic foot care and therapeutic shoes (external site) has more; see also keeping your foot in remission.

Charcot foot: from cast to CROW

During active Charcot foot with unbroken skin, a removable knee-high walker worn at all times is a fallback when a cast or locked walker isn’t possible. The guideline suggests not using shoes or sandals that stop below the ankle, because they don’t hold the bones still enough.⁠^[4]

Once Charcot settles in a foot with unbroken skin, the guideline recommends shoes and orthoses that fit and support the foot’s shape, to help keep it from flaring again. When deformity or instability remains, it recommends a custom below-knee device for added protection, such as a Charcot restraint orthotic walker (CROW) or a custom ankle-foot brace. Its authors suggest moving into footwear gradually, because loading the foot too fast may restart the process.⁠^[4] We can talk through whether a CROW or custom brace fits your foot.

Warmth, swelling or redness of one foot compared with the other can mean Charcot is active again.⁠^[4] If you notice it, call us the same day; see a red, hot, swollen foot.

When a boot isn’t enough: surgery

Sometimes the shape of the foot itself is the problem. Surgical offloading changes the foot’s structure, so it keeps relieving pressure even on days a device isn’t worn, though it carries its own risk of complications.⁠^[1]

If an ulcer under the ball of the foot or on the big toe hasn’t healed with non-surgical offloading, the guideline suggests considering surgery, along with an offloading device, to help it heal and stay healed. Depending on where the ulcer is, that may mean lengthening the Achilles tendon, removing the metatarsal head, an operation on the big-toe joint (arthroplasty) or cutting and resetting a metatarsal bone (osteotomy). For an ulcer on the tip or underside of a smaller toe caused by a flexible bent toe, it recommends releasing the flexor tendon.⁠^[1]

Dr. Ozturk is a Foot and Ankle Surgeon who is board certified in wound care (FAPWH). For the ulcers that need it, he performs tendon lengthening, flexor tendon release, metatarsal head resection and removing a bony prominence, as well as Charcot reconstruction. See offloading surgery and the Center for Lower Extremity Surgery’s page on gastrocnemius recession (external site).

Limits and risks

A boot is one part of the plan: infection and poor blood flow need their own treatment.⁠^[1] See peripheral artery disease. Removable knee-high boots may also lead to more falls than ankle-high ones, though that evidence is very uncertain.⁠^[1] The main harm from shoes, inserts and braces on a numb foot is a new ulcer from poor fit.⁠^[4] Ulcers on the heel, or on the top or sides of the foot, follow separate guideline recommendations.⁠^[1] See heel ulcers and pressure injuries.

Questions to ask

• Which device suits my ulcer, and can I take it off at night?
• What should I wear on my other foot?
• When do I switch to therapeutic shoes?
• If the ulcer doesn’t heal or comes back, would surgery help?

When to seek care

See us within a day or two for any foot wound that isn’t healing, especially if you have diabetes.