Offloading heel ulcers

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Hi all,

I have been reading literature regarding offloading heel ulcers and come across a whole range of different devices and specialist footwear which have left me feeling a bit overwhelmed.

Basically I just want some advice on what you guys think is the best way to offload a heel ulcer?

Are total contact casts any good for a heel ulcer? - I've read that they arn't as effective with heel ulcers as other locations on the foot.

What kind of specialist footwear is the best? I've heard you can get footwear without the rearfoot platform? What is generally used in the nhs?

I'd be grateful for any advice

Thank you

 

First, ascertain the causative factors behind the tissue stress on the plantar aspect of the heel and formulate an appropriate treatment plan.

Generally speaking, you may consider external shoe modifications such as a SACH heel (solid ankle cushion heel) for the rearfoot. The posterior aspect of the SACH heel is comprised of a lower durometer Crepe to attenuate shock at heel strike and aids in decreasing the time at heel contact as it helps rock the foot into midstance. A forefoot rocker can also be incorporated into the sole to decrease pressure on the ball of the foot and aid in propulsion. Internal shoe modifications such as a silcone gel heel pad can increase shock absorption.

IMO, contact casts are best for noncompliant patients. Debride, apply appropriate dressing, and keep foot non-weightbearing.

When you see patients, especially diabetic patients, always evaluate their shoes. Improper and poor fitting shoes commonly cause foot problems.

Steven

 

We do as Steven has said with the S.A.C.H, but we also add a 6mm poron relief to the underside of the TCO.

But how can you be sure you have got the best outcome/off loading for your client? for us we use the Fscan inshoe system to check and re check we have done the best we can.

We have seen a few of the felt pad devices used for off loading but when checked using our in shoe system, they have been found to increase the pressure in the area of concern.

 

There is any number of interventions that can be engaged to get the right clinical outcome. As mentioned in previous threads it is very important to determine the cause and the capability of the affected tissues ability to heal once the pathological forces are removed or deflected.
As previously mentioned in this thread, diagnosing the cause via pressure measurement and evaluating your intervention is essential. The use of Dynamic In shoe pressure measurement (we use Parotec in our clinic) enables the practitioner to, after diagnostic measurement, evaluate the performance of his/her intervention. If the intervention proves to be not entirely successful, you are able to make changes with an onsite lab, stick on pads or simply semi compressed felt and re-evaluate the changes to get the optimal plantar pressure deflection.
We use the Parotec Dynamic In shoe pressure measurement system on all Diabetic patients at some stage in their treatment regime and during most biomechanical assessments/dispenses, measuring the treatment outcomes. Further to this our CAD CAM modelling is able to superimpose the pressure measurement over the clinical image of the foot (this is a photo of the plantar surface of the patients’ foot at the time of the scan) and design the device (in 3D) around the areas of increased load.
Again the type of shoe, materials used for pressure deflection and the type of wound/wound care are all to be carefully considered as all will directly affect the outcome of your efforts.