Overcoming The Challenges Of Offloading Neuropathic Plantar Foot Ulcers

We all have had the challenge of trying to determine the best way to offload patients who are either non-adherent or unable to have appropriate offloading. I have been treating a young male who has neuropathy and an undiagnosed neurologic disease.

The left lower extremity with the plantar ulceration is the “good” foot. This extremity allows him to continue to ambulate. The other lower extremity is weak and has limited function.

He cannot tolerate any type of restrictive offloading device, such as a total contact cast, controlled ankle motion (CAM) walker or surgical shoe. The patient cannot even tolerate a sneaker. He has a high risk of falling. Alternately, if you attempt to put this patient in a wheelchair, his lower extremities will become so weakened that he may not walk again. As you can see, it is a challenge. 

I recently went to the Symposium on Advanced Wound Care (SAWC) Fall in Las Vegas in September and heard a presentation on offloading. The speaker mentioned a type of offloading dressing called a football dressing. Rader and Barry discussed this football dressing previously in the journal Wounds.¹ The search for a repeatable, inexpensive and efficacious dressing that addresses the need for non-removable offloading of the neuropathic plantar forefoot ulcer is what led the authors to propose this model. It is a well-padded dressing using cast padding, gauze and Coban. In our version of this dressing, we use foam, abdominal pads, Kerlix and Ace wraps. We were already using this modality for this patient but were not aware that there was research on it.

I have been treating this patient for several months. I always had an uneasy feeling as if I could be doing more to offload his plantar ulceration. After hearing the presentation, I felt I was offering the patient something that physicians had used before and that research had proven to work.

Obviously, this was not as aggressive an offloading device as some others but often we need to think outside the box for our patients. I am sure you have had similar scenarios. It is not only about the ulcer. It is the greater picture that we must also consider. Every patient’s situation is different. In this case, we have continued to use this offloading method with good success and expect wound closure soon.

Reference

1. Rader AJ, Barry T. Football dressing for neuropathic forefoot ulcerations. Wounds. 2006;18(4):85-91.