Orthotic Management of Diabetic Foot Ulcers: A Systematic Review

Abstract Background: Diabetic foot ulcers (DFUs) are a major complication of diabetes mellitus, contributing substantially to morbidity, amputation risk and mortality. Orthotic interventions focusing on pressure redistribution and offloading are central to DFU prevention and treatment. Objective: To systematically review evidence on the effectiveness of orthotic interventions in DFU management, including ulcer healing, recurrence prevention, patient adherence and clinical outcomes. Methods: A systematic search of PubMed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, Web of Science and CINAHL databases was conducted from January 2013 to October 2025. Studies evaluating total contact casting (TCC), removable and non-removable offloading devices, custom-made orthotics, therapeutic footwear and emerging technologies were included. Two independent reviewers performed study selection, data extraction and quality assessment. Results: Strong evidence supports orthotic management in DFU care. TCC demonstrated the highest healing rates (75%–90%) and remains the gold standard for plantar ulcer offloading. Non-removable knee-high devices achieved superior healing (82%–89%) compared with removable devices. Custom-made orthotics reduced ulcer incidence and recurrence more effectively than prefabricated insoles. Therapeutic footwear with pressure-redistributing insoles and rocker soles reduced ulcer recurrence from approximately 50% to 20%. Overall, orthotic interventions reduced recurrent ulceration from 79% to 15% and significantly lowered amputation rates. Patient adherence emerged as a critical determinant of outcomes, particularly with removable devices. Conclusions: Orthotic management is fundamental to DFU treatment and prevention. Non-removable offloading devices, especially TCC, should be first-line therapy when appropriate, while custom orthotics and therapeutic footwear are essential for long-term ulcer prevention.