Offloading Devices for Adults With Diabetic Foot Ulcer

Key Messages

What Is the Issue?

• Offloading devices provide mechanical support needed to alleviate pressure at the site of a diabetic foot ulcer. These devices protect the ulcer from further trauma to help with healing and prevent lower limb amputation.
• There are different types of offloading devices available, and suitability may differ based on ulcer severity and ulcer location.
• Health care decision-makers may be uncertain about best practices for implementing the use of offloading devices and related care for adults with diabetic foot ulcers. This Rapid Review was prepared in response to a request from decision-makers.

What Did We Do?

• We sought to identify evidence-based guidelines regarding the use of offloading devices to manage diabetic foot ulcers. We excluded guidelines focused solely on the use of these devices to prevent diabetic foot ulcers.
• We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published between January 1, 2021, and August 7, 2026.

What Did We Find?

• We found 5 relevant evidence-based guidelines (1 from Canada, 4 developed in the US or for international use).
• Overall, all guidelines recognize offloading devices as an important pressure offloading intervention for diabetic foot ulcers. Offloading devices may be considered as an adjunct treatment to surgery when ulcers persist after nonsurgical offloading. Shoe lifts for the contralateral limb may improve comfort and balance.
• Knee-high or ankle-high nonremovable offloading devices are recommended over removable types for plantar foot ulcers, including when mild infection or mild decreased blood supply is present.
• Removable offloading devices may be considered when people with plantar ulcers are experiencing:
  • both mild infection and mild decreased blood supply
  • moderate to severe infection and/or decreased blood supply.
• Felted foam may be considered when nonremovable or removable offloading devices are unavailable.
• Some guidelines suggest considering factors beyond ulcer location and severity when deciding on the device type, such as the lifestyle and preferences of the person with diabetic foot ulcer, as well as local resources and support available.

What Does This Mean?

• Offloading devices remain an important component of a comprehensive care plan for managing diabetic foot ulcers.
• The care team may consider nonremovable offloading devices as their first choice for pressure offloading plantar diabetic foot ulcers, specifically total contact casts or irremovable knee-high cast walkers. They may wish to explore prescribing other offloading device types with consideration of contraindications, presence of infection and/or decreased blood flow, device availability, the lifestyle and preferences of the person living with the diabetic foot ulcer, as well as local resources and care available.
• Decision-makers may wish to assess feasibility of implementing these guidelines in practice. Most recommendations may have limited applicability in Canada and likely did not consider the perspectives of populations disproportionately affected by diabetic foot ulcers in Canada.