Pressure and the diabetic foot: clinical science and offloading techniques.

Diabetic foot ulceration is a common, yet in many cases an eminently preventable, complication that affects 1 in 20 patients with diabetes. Risk factors for ulceration include insensitivity (secondary to somatic neuropathy), high foot pressures, callus formation (a consequence of sympathetic neuropathy and high foot pressures), deformities (such as claw feet, prominent metatarsal heads, etc.), peripheral vascular disease, and most importantly, a past history of ulceration. None of these factors alone causes ulceration; thus, early identification and amelioration of these factors is a primary aim in foot ulcer prevention. A number of therapeutic approaches may help reduce ulcer incidence: these include therapeutic footwear, hosiery, and, potentially, liquid silicone injected under high-pressure areas. In the management of neuropathic ulcers, pressure relief is of the utmost importance, and total contact casting remains the "gold standard" means of achieving such pressure redistribution. The successful management of diabetic foot ulceration depends on a team approach, remembering that ulcers should heal if (1) the arterial circulation is intact, (2) pressure relief is achieved and maintained over the ulcer, and (3) infection is appropriately treated.