When should a walking boot (orthopedic boot) be placed on a patient?

When to Use a Walking Boot (Orthopedic Boot)

A walking boot should be placed when treating neuropathic plantar forefoot ulcers without ischemia or uncontrolled infection, active Charcot neuro-osteoarthropathy, or when conservative treatment fails for ankle fractures requiring immobilization and offloading. 1

Diabetic Foot Ulcers

Primary Indications

• Neuropathic plantar forefoot ulcers without ischemia or uncontrolled infection:
  • First-line treatment: Non-removable knee-high device (total contact cast or non-removable walker) 1
  • Second-line treatment: Removable knee-high walker when non-removable devices are contraindicated or not tolerated 1

Hierarchy of Offloading Devices

1. Non-removable knee-high devices (strongest recommendation):

   • Total contact cast (TCC)
   • Removable walker rendered non-removable with cast material or tie wraps

2. Removable knee-high walkers (when patient adherence is expected):

   • Only when non-removable devices are contraindicated or not tolerated

3. Ankle-high devices (when knee-high devices cannot be used):

   • Forefoot offloading shoes
   • Cast shoes
   • Custom-made temporary shoes

Charcot Neuro-Osteoarthropathy (CNO)

Active CNO Management

• Immediate immobilization with a non-removable knee-high offloading device when active CNO is suspected 1
• Continue until clinical signs resolve (typically 4-6 weeks after resolution)
• Prefer total contact cast (TCC) over prefabricated walkers when possible 1
• Consider partial weight-bearing with assistive devices (crutches, walkers) 1

CNO in Remission

• Transition to therapeutic footwear that accommodates foot deformity 1
• Consider custom-made orthotics to redistribute plantar pressure

Fractures and Acute Injuries

Post-Surgical Management

• 6 weeks after surgical internal fixation for ankle fractures:
  • Walker boots reduce pain and improve gait symmetry compared to elastic bandages 2
  • Consider stirrup braces as an alternative with slightly less pain reduction

Acute Lateral Ankle Sprains

• Grade I and II sprains: Early mobilization preferred over prolonged immobilization 3
• Grade III sprains: May benefit from short-term immobilization (1-3 weeks)

Important Considerations

Biomechanical Effects

• Walking boots create leg length discrepancy (LLD) 4, 5
• Compensatory mechanisms include:
  • Increased hip and knee abduction during swing phase
  • Altered joint loading patterns
  • Reduced walking speed

Mitigating Side Effects

• Consider shoe lift for the contralateral foot to reduce LLD 5, 6
• Evenup™ shoe-lift users show improved function and reduced low back pain 6

Contraindications

• Avoid in ischemic ulcers without signs of infection
• Not recommended for conventional or standard therapeutic shoes to heal plantar foot ulcers 1

Pitfalls to Avoid

1. Prolonged immobilization can lead to muscle weakness, atrophy, and poorer outcomes 3
2. Delayed treatment of active CNO can result in severe foot deformity 1
3. Failure to address leg length discrepancy may cause secondary knee, hip, and low back pain 4, 5
4. Walking barefoot or in socks should be avoided for at-risk patients with diabetes 1
5. Improper fit can cause skin breakdown or inadequate immobilization

By following these evidence-based guidelines for walking boot use, clinicians can optimize healing while minimizing complications and improving patient outcomes.