Can a patient with ischemic toes, particularly an older adult with a history of peripheral arterial disease (PAD), diabetes, and hypertension, bear weight on the affected area?

Weight Bearing on Ischemic Toes

Patients with ischemic toes should NOT bear weight on the affected area, as weight bearing creates pressure that further compromises already inadequate perfusion and prevents wound healing. 1

Immediate Assessment Required

Before any weight bearing decisions, you must quantify the degree of ischemia:

• Measure toe pressures, ankle-brachial index (ABI), and transcutaneous oxygen pressure (TcPO2) to determine severity of arterial insufficiency 1
• Healing is severely impaired when toe pressures are <50 mmHg, TcPO2 <30 mmHg, ankle pressure <50 mmHg, or ABI <0.6 1
• Critical limb-threatening ischemia (CLTI) is defined by toe pressure <30 mmHg or TcPO2 <30 mmHg 1

Pressure Offloading Strategy

All patients with ischemic foot wounds require complete pressure offloading to promote tissue growth and wound healing. 1

Recommended Non-Weight Bearing Options:

• Total contact casting or other casting techniques for plantar ulcers (when perfusion adequate for healing) 1
• Non-weight bearing with crutches or wheelchair 1
• Limitation of standing and walking 1
• Chair exercises and arm exercises as alternatives to maintain activity 1

Contraindicated Weight-Bearing Activities:

The following exercises are specifically contraindicated in patients with loss of protective sensation and ischemia:

• Treadmill walking 1
• Prolonged walking 1
• Jogging 1
• Step exercises 1

Critical Pitfall to Avoid

The combination of ischemia and pressure creates a vicious cycle where metabolic demand from weight bearing exceeds the compromised blood supply, leading to tissue necrosis and amputation. 2 Even if the patient has neuropathy and cannot feel pain, weight bearing on ischemic tissue causes progressive damage. 3

Revascularization Before Weight Bearing

If measurements indicate significant ischemia (toe pressure <50 mmHg, TcPO2 <30 mmHg), revascularization should always be considered before allowing weight bearing. 1

• Urgent vascular imaging and revascularization consultation are required when ischemic ulcers fail to improve despite offloading 4
• The goal is restoring direct arterial flow to achieve minimum toe pressure ≥30 mmHg or TcPO2 ≥25 mmHg 4, 2
• After successful revascularization, limb salvage rates reach 80-85% with ulcer healing in >60% at 12 months 4

When Weight Bearing May Resume

Weight bearing should only be considered after:

• Successful revascularization with documented improvement in perfusion parameters (toe pressure >30 mmHg, TcPO2 >25 mmHg) 4, 2
• Complete wound healing or adequate granulation tissue formation 5
• Fitting with customized pressure-offloading footwear that accommodates and protects the foot shape 1

Special Considerations for Diabetic Patients

Patients with diabetes and peripheral arterial disease require proper footwear with silica gel or air midsoles and polyester or cotton-polyester blend socks to prevent blisters. 1 However, this applies only after adequate perfusion is restored. Individuals must monitor closely for blisters and potential damage both before and after physical activity. 1

Even with "normal" ABI readings, 70% of diabetic patients with foot ulcers have significant arterial disease in the foot detected by toe pressures, making distal assessment mandatory. 6 Do not rely on ABI alone due to arterial calcification causing falsely elevated readings. 7, 6

Multidisciplinary Approach

Podiatrists or foot-trained professionals (orthopedic surgeons, orthotists, prosthetists, specialist nurses) should evaluate these patients for appropriate pressure offloading strategies. 1 Treatment requires coordination between vascular surgery, wound care specialists, and endocrinology (if diabetic). 2