At the Symposium on Advanced Wound Care (SAWC) Spring 2026 in Charlotte, NC, Paul Kim, DPM, MS, and Johanna-Marie Richey, DPM, delivered a clinically focused discussion on offloading, surgical decision-making, and limb preservation in diabetic foot ulcer (DFU) management. They emphasized that clinicians must correct underlying biomechanical abnormalities—not just achieve wound closure—to ensure durable healing. Both speakers advocated for a structured approach that integrates patient-level factors, mechanical assessment, and targeted intervention.

Assessment of Healing Potential

Dr. Kim outlined a practical framework for evaluating healing potential, focusing on bacterial burden, perfusion, tissue quality, and biomechanics. He emphasized that clinicians must evaluate these factors alongside patient-specific “host” variables, including nutritional status, social support, access to care, and overall medical complexity.

He highlighted mobility as a key clinical indicator that directly affects both healing and long-term outcomes. Clinicians should prioritize preserving mobility, he said, as loss of function has significant downstream consequences for patient health and independence.

Biomechanical Evaluation of the Foot

The session placed strong emphasis on biomechanics as a primary driver of DFU development and recurrence. Dr. Kim described the foot as a structure that must remain both flexible and rigid. When this balance is disrupted—due to deformity, neuropathy, or prior surgical intervention—focal pressure increases and tissue breakdown can follow.

He encouraged clinicians to rely on straightforward but intentional examination techniques. These include visual inspection of both plantar and dorsal surfaces, assessment of deformities, evaluation of joint range of motion, and observation of gait. Restricted motion, altered structure, and prior amputations all contribute to abnormal load redistribution. He cautioned that progressive removal of foot structures often leads to biomechanical instability and high rates of reulceration.

He also recommended using weight-bearing imaging to better understand structural alignment under physiologic load, as non-weight-bearing studies may miss clinically relevant deformities.

Mechanical Forces and Wound Characteristics

Dr. Kim emphasized that understanding the type of mechanical force driving ulceration is critical for effective offloading. He distinguished between sagittal loading forces and shear forces, noting that clinicians can often infer the dominant force based on wound morphology. Circular wounds tend to reflect sagittal pressure, he said, while elongated or oval wounds suggest shear.

Because direct measurement of shear remains limited in clinical practice, he advised clinicians to integrate multiple observations, including wound shape, gait pattern, and footwear wear patterns. This approach allows for more targeted offloading strategies rather than treating all plantar ulcers in the same manner.

Role of Nonoperative Offloading

Dr. Richey reinforced that clinicians must prioritize nonoperative offloading before considering surgical intervention. She noted that many patients referred for surgery have not undergone adequate offloading, which remains essential for healing plantar ulcers.

She discussed common offloading strategies, including therapeutic footwear, custom inserts, shoe modifications, and ankle-foot orthoses. However, she emphasized that these interventions depend on the presence of a braceable deformity. In cases of significant instability, orthotic management alone may not sufficiently redistribute pressure, and clinicians must consider alternative approaches.

Surgical Offloading Strategies

Dr. Richey presented surgical intervention as a targeted option when conservative measures fail or when structural deformity prevents effective offloading. She emphasized that procedure selection should directly address the underlying biomechanical abnormality.

She described flexor tenotomy as an example of a lower-risk, minimally invasive option for distal digital ulcerations associated with flexible deformities. For forefoot ulcers driven by focal pressure, she discussed distal metatarsal osteotomy as a method to reduce plantar load. She also reviewed Achilles tendon lengthening and gastrocnemius recession as strategies to address equinus, while cautioning that these forefoot and rearfoot procedures carry risks, including transfer lesions.

Amputation and Limb Preservation

Dr. Richey emphasized that clinicians should view minor amputations within a limb preservation framework, with the goal of maintaining function and avoiding progression to major amputation. She noted that transmetatarsal amputation carries significant morbidity and should not be considered a simple solution.

Successful outcomes depend on achieving three key elements:

• Complete wound healing
• A stable soft tissue envelope
• A biomechanically functional residual limb

She also highlighted the importance of avoiding central ray resections due to the high risk of transfer lesions. In the setting of infection, she advocated for staged surgical management, beginning with source control and followed by delayed reconstruction and biomechanical correction once the patient stabilizes.

Clinical Implications

The session reinforced the need for a structured, multidisciplinary approach to DFU management. Clinicians must integrate patient-level factors, perform detailed biomechanical assessments, and implement effective offloading early in the treatment course. When necessary, they should use surgery selectively and with a clear mechanical objective.

Conclusion

Through their session, Dr. Kim and Dr. Richey emphasize that clinicians must move beyond wound closure and address the underlying mechanical and patient-specific drivers of DFUs. By combining careful assessment, appropriate offloading, and targeted surgical intervention, wound care providers may help to reduce recurrence and preserve long-term limb function.