Is postural instability exacerbated by off-loading devices in high risk diabetics with foot ulcers?

Pressure reduction is of pivotal importance in any treatment plan designed to heal diabetic foot ulcers. However, to our knowledge, no work has evaluated the effect of ambulatory pressure reducing devices on postural stability (PS) in high risk diabetics. Therefore, the purpose of this study was to compare PS associated with 5 off-loading strategies: total contact casts with cast boot, total contact casts with heel, removable cast walker, half-shoes, and canvas shoes using a repeat measure design. Twenty-six diabetic patients with foot ulcers were enrolled in the study. Using a digital pressure platform, the degree of sway was measured as total deviation of center of force. Three 30 second trials were evaluated using Turkey's studentized range test for multiple comparisons (alpha = 0.05). Sway was significantly greater with total contact casts with heel compared to other devices. While total contact casting remains the gold standard with which to treat neuropathic ulcers, care should be taken when placing patients in any devices that may exacerbate postural instability. The results suggest that total contact casts with an incorporated rubber heel may indeed accentuate sway. It is therefore recommended that the rubber heel be eliminated in lieu of a protective cast boot when using this modality.