Priorities in offloading the diabetic foot

Biomechanical factors play an important role in diabetic foot disease. Reducing high foot pressures (i.e. offloading) is one of the main goals in healing and preventing foot ulceration. Evidence-based guidelines show the strong association between the efficacy to offload the foot and clinical outcome. However, several aspects related to offloading are underexposed. First, in the management of foot complications, offloading is mostly studied as a single entity, whereas it should be analysed in a broader perspective of contributing factors to better predict clinical outcome. This includes assessment of patient behavioural factors such as type and intensity of daily physical activity and adherence to prescribed treatment. Second, a large gap exists between evidence-based recommendations and clinical practice in the use of offloading for ulcer treatment, and this gap needs to be bridged. Possible ways to achieve this are discussed in this article. Third, our knowledge about the efficacy and role of offloading in treating complicated and non-plantar neuropathic foot ulcers needs to be expanded because these ulcers currently dominate presentation in multidisciplinary foot practice. Finally, foot ulcer prevention is underexposed when compared with ulcer treatment. Prevention requires a larger focus, in particular regarding the efficacy of therapeutic footwear and its relative role in comparison with other preventative strategies. These priorities need the attention of clinicians, scientists and professional societies to improve our understanding of offloading and to improve clinical outcome in the management of the diabetic foot.