Diabetic foot ulcers (DFUs) are one of the most common causes of hospitalizations and non-traumatic lower-limb amputation (NLLA) in the world and offloading mechanical stress is considered as the most effective intervention for healing plantar neuropathic ulcers.

A narrative synthesis of evidence from peer-reviewed randomized controlled trials, systematic reviews and meta-analyses and international guideline documents (International Working Group on the Diabetic Foot [IWGDF], Diabetes Care, Diabetic Medicine, and related journals) was carried out.

Non-removable knee-high devices (particularly the total contact cast [TCC] and cast walkers that cannot be removed) have been shown to consistently improve time to healing and healing rate over removable devices, due to increased adherence to treatment. Removable cast walkers (RCWs) and therapeutic footwear are more functional but poorly adhered to by patients resulting in a diminished biomechanical advantage. Recurrent or refractory ulceration occurs and surgical offloading (Achilles tendon lengthening, metatarsal head resection, digital flexor tenotomy) contributes. New technologies such as smart insoles, orthoses printed with sensors, and walkers with sensors have potential to enhance adherence and tailor pressure redistribution.

Non-removable knee-high offloading is the evidence-based gold standard for plantar neuropathic DFUs, though practice is changing as technologies to improve adherence and surgical alternatives become increasingly available, especially when casting isn't a consideration or is poorly tolerated.