Reviewed for medical accuracy by Dr Evelyne Jonniaux, Medical Advisor
Last updated 17 September 2026
For healing a diabetic foot ulcer, offloading with a non-removable device is the best demonstrated intervention. For preventing recurrence, by contrast, the only measure whose confidence interval excludes no effect is skin temperature monitoring. Optimised footwear, education and integrated care do not reach significance.
The questions we get asked
Why is offloading the central act?
Because it is the only one whose effect is clear. A Cochrane review of 14 trials shows that a non-removable cast heals more ulcers than a removable device, and more than dressings alone. The important word is “non-removable”: a device that can be taken off is taken off.
The international guideline ranks, in order, the non-removable knee-high device, then the removable knee-high, then the removable ankle-high, and last the adapted shoe.
And preventing the ulcer coming back?
This is where the trials disappoint relative to the rhetoric. Two good-quality randomised trials, published a year apart in the same journal, on the same question, give opposite results. One finds a benefit of orthoses designed from plantar pressure, on ulcers alone. The other, on pressure-optimised footwear, finds no difference by intention to treat: 38.8 percent recurrence against 44.2.
Yet that negative trial holds the key. Among patients who actually wore their shoes for more than 80 percent of their steps, 46 percent of the sample, recurrence falls from 47.8 to 25.7 percent. Its authors conclude that optimised footwear does not reduce recurrence, “unless it is worn as recommended”.
Does the monofilament detect neuropathy?
Less well than is claimed. Its pooled sensitivity is 0.53, and 0.43 in women. A negative test is therefore not very reassuring. It remains useful because it is simple and immediate, but it does not replace a full foot examination.
What is really at stake?
Far more than the foot. A meta-analysis of 124,376 patients gives survival of 86.9 percent at one year after an ulcer, 50.9 percent at five years, 23.1 percent at ten. Nearly half the deaths are cardiovascular. The ulcer is as much a marker of general risk as a local problem.
And a minor foot lesion multiplies ulcer risk by 9 to 11. That is what justifies seeking advice quickly for a blister or a fissure, not only for an open wound.
What the figures say
| Finding | Figure | Source |
|---|---|---|
| Non-removable against removable offloading, healing | relative risk 1.17 | Cochrane, 2013 |
| Optimised footwear, preventing recurrence | 38.8 against 44.2 percent, not significant | DIAFOS trial, Diabetes Care, 2013 |
| Same trial, patients adherent above 80 percent | 25.7 against 47.8 percent | DIAFOS, 2013 |
| Monofilament sensitivity | 0.53, and 0.43 in women | meta-analysis |
| Survival 5 years after an ulcer | 50.9 percent | Chen et al., Diabetes Obes Metab, 2023 |
| Global prevalence of diabetic foot ulcer | 6.3 percent | Zhang et al., Ann Med, 2017 |
Two widespread figures we could not properly source. “75 percent of ulcers are preventable” is a target proposed in a position paper, not a measurement. And “85 percent of amputations are preceded by an ulcer” comes from a series of 80 amputations in a single US centre between 1984 and 1987.
What Noria Health does, and does not do
We organise a podiatry and vascular medicine consultation with a specialist team near Brussels, foot examination, assessment for peripheral arterial disease and footwear review included, and confirm feasibility within 24 to 48 hours.
We do not manage a wound remotely. A foot wound in a person with diabetes is a relative emergency: it needs to be seen, not described by message. If you have an active wound, seek care without waiting for a reply from us.
Who reviewed this page
Noria Health editorial team.
See also: all our articles on posturology and podiatry.
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