From the Guidelines
For a 70-year-old patient, I would not recommend placing her in a boot without first assessing the specific nature of her foot injury, but if she has a neuropathic plantar forefoot or midfoot ulcer, a non-removable knee-high offloading device should be considered as the first choice of offloading treatment. When deciding on the best course of action for this patient, it's crucial to consider the guidelines on offloading foot ulcers in persons with diabetes, as outlined in the 2023 update by the International Working Group on the Diabetic Foot (IWGDF) 1.
The key considerations include:
- The location and type of the ulcer, as different areas of the foot may require different offloading strategies.
- The presence of any infection or ischaemia, which could necessitate a different approach, such as primarily addressing these issues before considering offloading devices.
- The patient's individual factors, including tolerance for different types of offloading devices and the need for specific interventions like Achilles tendon lengthening or metatarsal head resection if non-surgical offloading treatment fails.
Given the patient's age and potential for underlying conditions like diabetes, which significantly impact foot health, a thorough assessment is necessary to determine the best offloading strategy, with a focus on promoting healing of the ulcer while considering the patient's comfort, mobility, and overall quality of life. This might involve the use of a total contact cast (TCC) or a non-removable knee-high walker, chosen based on local resources and the patient's individual factors and acceptability, as suggested by the IWGDF guidelines 1.
In cases where a non-removable knee-high offloading device is contraindicated or not tolerated, consideration should be given to using either a removable knee-high or ankle-high offloading device as the second choice of offloading treatment, with the patient encouraged to use the device during all weight-bearing activities 1. Ultimately, the goal is to select an offloading strategy that balances the need for ulcer healing with the patient's overall morbidity, mortality, and quality of life.
From the Research
Treatment Options for Neuropathic Pain
- The provided studies do not directly address the treatment of a 70-year-old patient or the use of a boot for neuropathic pain management 2, 3, 4, 5, 6.
- However, the studies discuss various treatment options for neuropathic pain, including:
- Gabapentin, which has been shown to be effective in reducing the intensity and frequency of pain in patients with neuropathic pain 2, 3.
- Pregabalin, duloxetine, and tapentadol, which are FDA-approved treatments for painful diabetic neuropathy 5, 6.
- Spinal cord stimulation and transcutaneous electrical nerve stimulation, which have shown promise in reducing pain in patients with diabetic neuropathy 5, 6.
Considerations for the 70-Year-Old Patient
- When considering treatment options for a 70-year-old patient, it is essential to take into account the patient's overall health, medical history, and potential interactions with other medications.
- The patient's age and potential comorbidities may affect the efficacy and safety of certain treatments, and alternative options may need to be considered.
- A thorough evaluation of the patient's condition and a discussion of the potential benefits and risks of each treatment option are necessary to determine the best course of treatment.
Use of a Boot for Neuropathic Pain Management
- There is no mention of using a boot as a treatment option for neuropathic pain in the provided studies 2, 3, 4, 5, 6.
- The use of a boot may be considered for other conditions, such as foot or ankle injuries, but its effectiveness in managing neuropathic pain is not supported by the available evidence.