Padding and offloading

What is padding and offloading?

Padding and offloading means using cushioning materials or devices to take pressure off a vulnerable spot on your foot, so it can heal or avoid further breakdown¹. The aim is to ease downward pressure, rubbing (shearing) force and strain on the tissue¹.

Podiatry felt padding is one common way to do this. It's an adhesive-backed pad that stays in place and takes pressure off a small area². Larger options include casts, walking boots and pressure-relieving footwear. Padding doesn't replace working out why the spot is under pressure in the first place.

What is it used for, and how well does it work?

It's best supported for ulcers on the sole of the forefoot or midfoot in adults with diabetes and nerve damage. For these, a cast or boot that you can't take off is the first choice. Padding with felted foam (a layered foam-and-felt material) is a lower choice, for when no device is available³. Felted foam with a hole cut at the ulcer, fixed to the foot or insole inside a removable ankle-high boot, seems to heal ulcers better than the boot alone⁴.

Pressure-relieving footwear that you actually wear helps prevent ulcers coming back, but clear proof that felted foam heals ulcers is still limited⁵. Heel pressure injuries are treated with local wound care plus offloading⁶. For sesamoiditis (pain under the big toe joint), a felt pad in the shoe or on the foot can cushion the area⁷.

Most of this applies to adults with diabetes and ulcers on the forefoot or midfoot. It doesn't cover heel ulcers, ulcers on top of the foot or children⁸. Results also depend on wearing the device: using offloading for at least 80% of your daily activity is considered essential⁹.

Is it right for me?

Casts or boots that can't be taken off shouldn't be used with a soft tissue infection, a bone infection, severe circulation problems or severe swelling of the lower leg or foot¹⁰. A clinician should check for these first.

Felt padding can be used with a mild to moderate infection¹⁰. It isn't suitable for heavily discharging wounds or wounds with undermining (where damage runs under the skin edge), and it must be kept dry².

What happens during padding and offloading?

A trained clinician applies and checks the padding. Felt can be applied quickly, needs no extra hospital appointments, and lets the wound be seen at each dressing change¹⁰.

Padding flattens after a short time, so it needs replacing regularly¹⁰. Ask for it to be re-checked at each dressing change. A podiatrist changes the dressings regularly¹¹. Keep your follow-up visits so someone can check the offloading is working and that you're wearing your device or footwear.

A cast that can't be removed ensures it stays on, while removable devices can be taken off, so wearing them as instructed matters¹⁰.

Are there risks or side effects?

The main risks come from casts that can't be removed. They can irritate the skin and stop you checking the ulcer daily¹⁰, and they're linked with more device-related problems than removable options⁹. Reduced feeling in your feet can hide cuts, blisters and rubbing under any device.

Surgery to lengthen the Achilles tendon is considered only if other methods haven't worked, because it carries higher costs and risks¹⁰. It can also lead to new heel ulcers¹².

How does it compare with other options?

For ulcers in people with diabetes, the order is a non-removable knee-high device first, a removable device second, and footwear with felted foam third³. Casts that can't be removed heal more non-infected ulcers than removable devices or felt¹⁰. When casts are compared separately with removable walking casts or footwear, the difference in healing time isn't clear-cut⁹. Removable knee-high and ankle-high devices heal ulcers equally well⁴.

If you're offered padding, ask whether it's being used alone or inside an offloading device, and whether a cast or walker is also an option. The best choice is the one you can wear for most of your walking time.