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Pressure Relief
Guidelines for use in
the Management of the
Diabetic Foot
Anne Hedridge Lead Orthotist
Ian Smith Senior Orthotist
Kathleen Spence Chief Podiatrist
Pressure Relief Guidelines for use the Management of the Diabetic Foot
July 2005
1
Introduction
This document aims to provide guidelines for pressure relief
management of the diabetic foot. Early diagnosis of at risk feet
and proactive monitoring has been demonstrated to reduce
numbers proceeding to amputation. It is clear form the evidence
that 50% of all non-traumatic amputations are diabetes related
and 80% of diabetes related amputations are preceded by foot
ulceration (Pecoraro et al, 1990). Foot screening plays an
important part in identifying those at risk. The risk factors, which
predispose a person to ulceration, are peripheral neuropathy,
peripheral vascular disease, previous amputation, previous
ulceration, the presence of callous, joint deformity, visual and
mobility problems. In the insensate foot, a painless corn or
commonly precedes painless ulceration, making pressure control
mandatory for prevention of skin breakdown. Studies have
suggested that customised footwear is beneficial (Edmonds et al,
1986), resulting in an ulcer recurrence rate of 19%, compared
with a 90% relapse rate when the patient’s regular shoes are
worn. The “high risk” foot requires preventative measures to be
considered:
 Appropriate pressure relief
 Prescriptive footwear.
It is important that any patient with an active ulceration or those
who have been identified as being at “high risk” of diabetic foot
ulceration must be assessed and considered for a managed
program of pressure relief and or prescription footwear.
Pressure Relief Guidelines for use the Management of the Diabetic Foot
July 2005
2
Education
The diabetes multidisciplinary team has a responsibility to
provide appropriate education to enable patients to acquire the
necessary knowledge and skills to take responsibility for
managing their own foot health care. This will allow them to alter
their lifestyle in such a way as to maximise their foot health and
reduce the risk of complications.
Patients at risk of ulceration need to know how ulceration can be
caused, how footwear can precipitate ulceration and what the
patient’s role is in preventing and healing diabetic foot ulceration.
Simple advice such as daily foot checks, daily footwear checks
and how to access the appropriate care when require can reduce
future problems.
Education should be given verbally and in written form and
needs to be reinforced at regular intervals with all members of
the multidisciplinary team giving the same advice. Education
does make a difference. (Boulton 1994, Barth 1991)
Foot Screening
Dividing patients into risk categories clearly predicts the risk of
ulceration and amputation (Peters EJ, Lavery LA. 2001).
Therefore all people with diabetes should have diabetic foot
screening annually (SIGN guidelines 55) and the risk category
recorded. Across NHS Grampian those professionals with the
appropriate training will provide foot screening. (Appendix 1)
Pressure Relief Guidelines for use the Management of the Diabetic Foot
July 2005
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Low to Moderate Risk
Those who have been assessed as being of low to moderate risk
require:
Verbal and written advice on suitable footwear and fitting
For example
Footwear requirements:
 Adequate depth, length and width
 Cushioned insoles
 Leather uppers
 Adjustable fastening
 Foot shaped shoe
 No stitching on the upper
 Wear the footwear appropriate to the activity
Day to day foot care routine including
 Daily foot checks
 Daily shoe checks
 When to access the appropriate care
Moderate to High Risk
Patients who have received annual foot screening and are
classified as moderate or high risk of foot ulceration require.
Verbal and written advice on the following topics:
 Abnormal foot shape
 Loss of fatty padding
 Loss of protective sensation
 Limited joint mobility
Pressure Relief Guidelines for use the Management of the Diabetic Foot
July 2005
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These
patients
require
to
be
referred
to
Mobility and
Rehabilitation Service (MARS) to be assessed for stock /
bespoke footwear depending on their level of risk and deformity.
Insoles
The patient’s own footwear must be assessed carefully for depth
and width before considering the suitability of the shoes for
insoles. When the patient is referred to the Orthotist for footwear
this should include a referral for insoles.
Good podiatric care is essential because the removal of reduces
high foot pressures by up to 26% (Young et al, 1992). Please
refer to the podiatry department using the guidance on the
Diabetic Foot Risk Assessment Form. (Appendix1)
Active foot Ulceration
All patients with an active foot ulcer should be referred to the
appropriate Specialist Diabetes Podiatrist.
Please refer to guidance - Appendix 1, Diabetic Foot Risk
Assessment Form. All people with diabetic foot ulceration are to
be reviewed by a Diabetes Foot Specialist. (NHS QIS CSBS
Standards) Only Consultant led medical teams can make a
referral to the Oththotic Department within the Mobility and
Rehabilitation Service. Please refer the patient to the designated
Specialist Diabetes Podiatrist for the appropriate Community
Health Partnership (CHP) or Acute Hospital in which you work
with in and the referral will be made via the appropriate
Consultant team. (Diabetic or Vascular).
Pressure Relief Guidelines for use the Management of the Diabetic Foot
July 2005
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PRESSURE RELIEVING DEVICES
IPOS boots
Rearfoot relief
To relieve pressure on the plantar aspect of the heel by
transferring body weight to mostly through the forefoot
Forefoot relief
To relieve pressure from the plantar aspect of the forefoot by
transferring body weight to mostly through the hindfoot.
Contraindications:
 Do not use of patient has poor balance of is blind/partially
sighted.
DH boots:
Relief of plantar ulceration is provided through the removal of
hexagonal segments from the inside of the boot.
Can be used to treat multiple ulceration
Indications:
 Ulcers/multiple ulcers on plantar aspect of foot.
 Patient with poor balance,
 Partially sighted/blind.
Multi purpose boots/AP boots/ Supercity boots:
All are temporary accommodative footwear where bulky
dressings have to be accommodated i.e. ulcers on dorsum of
foot.
Indications:
Pressure Relief Guidelines for use the Management of the Diabetic Foot
July 2005
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 Foot ulceration requiring accommodating dressings on dorsum
of foot.
Multipodus / PRAFO
(Pressure relieving ankle foot orthoses)
To relieve pressure over the posterior heel. This allows very
limited mobilisation i.e. transferring. Can be worn in bed with sole
plate
removed.
Extension
bar
to
prevent
excessive
internal/external rotation of leg. Strong frame with soft covering
and velcro fastening.
Indications:
 Posterior heel ulcers
 Patient must be able to transfer
Heel relief boot
Soft foam boot to relieve posterior heel pressure in bed.
Cannot be used when mobilising.
Indications:
 Posterior heel ulcers,
 Non ambulant patient.
Aircast Pneumatic Diabetic Walker
Prefabricated bivalved plastic boot, covering lower leg and foot.
Plastazte foot bed and segmented air cells lining.
The individual cells pressures are controlled via a pump and
gauge.
Indications:
 Charcot joint,
 Chronic ulcer control.
Pressure Relief Guidelines for use the Management of the Diabetic Foot
July 2005
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Deflective and cushion padding
Adhesive padding and strapping is not generally recommended
for use on the high-risk diabetic foot because of the trauma
caused on removal.
However in some circumstances where
other effective methods are not available its use is acceptable for
short periods with close monitoring.
Contra indication
Ischaemia
ALTERNATIVE THERAPIES
Scotch Slipper Cast
Mobilising foot covering made directly onto the individuals foot
from a combination of felt, bandages, fibreglass and tape.
Indications:
 Plantar ulcer. Allows frequent replacement of pressure relieving
felt to be replaced every 2-3 days. This maintains optimum
pressure relief by preventing felt from bottoming out.
ONLY to be applied by trained practitioner.
Total Contact Cast
ONLY to be applied by specially trained professional. As in the
scotch cast slipper, the total contact cast requires frequent
monitoring.
The cast requires to be totally removed and replaced at each
check.
Pressure Relief Guidelines for use the Management of the Diabetic Foot
July 2005
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PREVENTATIVE TREATMENT
Prevention of ulcer reoccurrence
Prevention hinges around education and regular review of feet
and footwear.
The following measures should be employed after a foot ulcer is
healed, prevention of reoccurrence is essential and pressure
relief must be continued. The patient must be referred to the
Mobility and Rehabilitation Service to be assessed for stock /
bespoke footwear and insoles. The referral for footwear must be
completed when formulating the initial care plan. Once the
patient has been reviewed by a Diabetes Specialist Podiatrist
and the foot ulceration is resolved it is important that the patient
is weaned off the pressure relief device gradually over a period
of 6 weeks.
The patient is advised to continue with their
pressure relief device for an agreed number of hours per day
and then swap into their footwear. The time the patient wears
the pressure relief device is reduced gradually until the patient is
wearing their footwear full time. It is essential during this weaning
off period the patient’s condition is assessed frequently by a
Diabetes Specialist Podiatrist.
Conclusion
Pressure relief is one of the most essential elements in the
prevention and treatment of diabetic foot ulcers and for those
patients who at risk of developing foot ulceration.
The chief
factors responsible for foot problems in these patients are
neuropathy and ischaemia. Ulcers can develop as a result of
trauma and repeated mechanical forces. A proactive screening
Pressure Relief Guidelines for use the Management of the Diabetic Foot
July 2005
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program can prevent many foot problems and multidisciplinary
team approach to pressure relief management, remembering the
patient’s knowledge, motivation and participation is essential.
Pressure Relief Guidelines for use the Management of the Diabetic Foot 10
July 2005
Summary
Low Risk
Diabetes Specialist Podiatrist will
initiate referral via Consultant Team
To MARS via Consultant Team
Moderate /
High Risk
High Risk- Acute
Ulceration
Ulcer Resolved
 Prevention –
reoccurrence of ulcer
 Education
 Basic Footwear
advice
 Education
 Intensive footwear advice
 Prescription Footwear for
feet with deformity
 Insoles









Education
IPOS Boots
DH Boots
PRAFO
Aircast Pneumatic
Diabetic Walker
Scotch Cast Boots
Total Contact Casts
Bed Rest
Other aids –
wheelchair, crutches
Pressure Relief Guidelines for use the Management of the Diabetic Foot 11
July 2005
Appendix 1
Diabetic Foot Risk Assessment Form
NAME:
DATE of BIRTH
& CHI NO:
ADDRESS:
MALE
FEMALE
GP NAME:
PHONE NO:
GP PRACTICE:
TYPE OF DIABETES:
TYPE I
TYPE II
CONTROLLED
BY:
Diet only
Tablets
Insulin
Physical Examination
AREA
FURTHER INFORMATION
Pulses
PULSES
RIGHT
LEFT
Callosities
Dorsalis Pedis
Present
Present
Absent
Absent
Present
Present
Absent
Absent
Diabetes
Related Lower
Limb
Amputation
Ulceration
Foot Deformity
YES
NO
Dorsalis Pedis
YES
NO
PAST YES
PRESENT YES
YES
PAST NO
PRESENT NO
Posterior
Tibial
Posterior
Tibial
NO
10g Monofilament Examination (please mark in circle whether present (√) or absent (X))
○ ○
○ ○
Any Other Information (i.e. self care, eyesight, footwear, podiatry, smoker)
ADVICE GIVEN:
WRITTEN
VERBAL
NONE
Risk Category
Low Risk
PRINT NAME:
Moderate Risk
High Risk
DESIGNATION:
DATE:
SIGNATURE:
July 2004
ONLY TO BE COMPLETED BY STAFF WHO HAVE UNDERTAKEN APPROPRIATE TRAINING
PHYSICAL EXAMINATION
CALLOSITY- PRESENCE OF THICKENED SKIN OVER BONY PROMINENCE.
AMPUTATION - PLEASE GIVE REASON AND RECORD LEG, FOOT, TOES ABSENT.
ULCERATION- RECORD SITE UNDER 'ANY OTHER INFORMATION'.
FOOT DEFORMITY - OUTWITH THE NORMAL.
PULSES
PALPATION OF DORSALIS PEDIS AND POSTERIOR TIBIAL PULSE SHOULD BE RECORDED.
VASCULAR IMPAIRMENT – THIS IS DEFINED AS TWO ABSENT PULSES ON EITHER FOOT
10g MONOFILAMENT - DEMONSTRATE ON PATIENTS' FOREARM BEFORE PROCEEDING TO TEST SITES ON FEET.
SIGNIFICANT NEUROPATHY IS DEFINED AS 3 OR MORE ABSENT SITES WHEN TESTED WITH A CALIBRATED
10g MONOFILAMENT
ANY OTHER INFORMATION
PLEASE WRITE IN FULL GIVING AS MUCH DETAIL AS POSSIBLE.
ADVICE GIVEN
NOTE ANY ADVICE GIVEN EITHER VERBAL, WRITTEN OR NONE.
RISK CATEGORY
LOW RISK – NORMAL SENSATION AND NO VASCULAR IMPAIRMENT AND NO PREVIOUS FOOT ULCER AND NO FOOT
DEFORMITY AND NORMAL VISION.
ACTION - ANNUAL FOOT SCREEN AND EDUCATION- NO SPECIFIC REGULAR PODIATRY INPUT REQUIRED. PATIENTS
CAN UNDERTAKE THEIR OWN NAIL CARE WITH THE APPROPRIATE EDUCATION.
MODERATE RISK – SIGNIFICANT NEUROPATHY OR VASCULAR IMPAIRMENT OR PREVIOUS VASCULAR SURGERY
OR SIGNIFICANT VISUAL IMPAIRMENT OR PHYSICAL DISABILITY (EG STROKE OR GROSS OBESITY).
ACTION - REFER TO GENERAL PODIATRY FOR REGULAR INPUT AND APPROPRIATE EDUCATION.
CHRONIC HIGH RISK (ANY OF THE FOLLOWING)
 ANY DIABETIC RELATED AMPUTATION
 PREVIOUS FOOT ULCER
 SIGNIFICANT NEUROPATHY AND VASCULAR IMPAIRMENT, DEFORMITY OR CALLOUS
 VASCULAR IMPAIRMENT AND SIGNIFICANT NEUROPATHY, DEFORMITY OR CALLOUS
ACTION - REFER TO DIABETES SPECIALIST PODIATRIST (COMMUNITY BASED) TO FORMULATE CARE PATHWAY.
ACUTE HIGH RISK
 ACTIVE FOOT ULCERATION
 PAINFUL NEUROPATHY WHICH IS DIFFICULT TO CONTROL
 SUSPECTED CHARCOT NEUROARTHROPATHY
ACTION - MAKE CONTACT WITH THE LOCAL SPECIALIST DIABETES TEAM VIA DIABETES PODIATRIST FOR
INTENSIVE THERAPY.
IN ADDITION, PATIENTS WITH ANY OF THE FOLLOWING SIGNS OF SEVERE ISCHAEMIA OR INFECTION SHOULD BE
CONSIDERED FOR EMERGENCY REFERRAL TO A DIABETIC FOOT CLINIC WITHIN SECONDARY CARE, DIABETES
RECEIVING TEAM OR VASCULAR RECEIVING TEAM.
CRITICAL LIMB ISCHAEMIA - REST PAIN
SEVERE INFECTION - ABSCESS
PALE/MOTTLED FEET
CELLULITIS
DEPENDANT RUBOR
ISCHAEMIC ULCERATION
GANGRENE
July 2004