Kristin Bojrab, PT, DPT, WCC, CFCS, CFNIP, DWC

Offloading is one of the most critical—and frequently underestimated—factors in healing diabetic foot ulcers (DFUs). In her recent WoundCon session, Kristin Bojrab, PT, DPT, WCC, CFCS, CFNIP, DWC, explores why specialty dressings alone are not enough and how gait mechanics, weight-bearing patterns, and interdisciplinary referral can dramatically improve healing outcomes. Learn how a big-picture, biomechanics-driven approach can set patients up for both short- and long-term success. 

Key Takeaways 

1. Without Offloading, Healing Is Unlikely. 
Research and clinical experience consistently show that therapeutic modalities and advanced dressings cannot overcome continued pressure and mechanical stress. Effective offloading is foundational to DFU healing, and without it, the risk of non-healing rises significantly. 

2. Gait and Biomechanics Directly Influence Healing Potential. 
Evaluating how a patient moves can change the trajectory of wound management. Personalizing offloading strategies based on gait mechanics helps reduce pressure at the wound site and optimize healing potential. 

3. A Big-Picture Strategy Improves Long-Term Outcomes. 
Successful DFU management extends beyond the wound itself. Clinicians must assess vascular status, imaging needs, and referral pathways, especially to podiatry, to ensure patients are set up for sustainable healing and prevention. Even in resource-limited settings, identifying local partners and creating continuity of care is essential. 

Why does offloading continue to be such a critical and sometimes underestimated factor when it comes to healing diabetic foot ulcers (DFUs)? 

We have found, and research supports, that without offloading, it's unlikely that any other therapeutic modalities will be successful. Your risk of not healing the ulcer will become super high. A specialty dressing alone will not heal the wound. 

From your experience, what changes when clinicians really start thinking about how a patient moves and bears weight? How does that ultimately play a role in wound management and healing? 

When it comes to thinking outside of the wound care perspective and adding in the mobility component, that’s what physical therapists specialize in. We look at their gait mechanics, how they bear weight from heel to toe and the biomechanics of their feet. This ultimately affects how much pressure is being put through the foot or through the wound, and ultimately will help us determine their healing potential, so there are ways that we can offload to support their specific gait pattern, and the weight that they're bearing through the foot. 

What do you hope that learners will come away with from your WoundCon session? Are there any specific tips, mindset changes, or perspective changes that you hope they're able to apply after they attend? 

I look at it as more a big picture perspective, so not just the offloading. I'm a physical therapist who specializes in wound care, and I work in a PT-driven wound clinic, so I do not have physician oversight. I don't work with nurse practitioners, I don't work with physician assistants, and so, for me, I have to look at the bigger picture, because patients don't come to me with the imaging that they need. I don't know their arterial status when they come to me, which helps me determine their healing potential. I don't have access to a podiatrist, and I think that that is probably one of the most critical factors I have found in my specific area, is the best thing that I can do for them is get them set up with a podiatrist who manages these patients more long-term. So, for me, the patient comes to me, hopefully I get them to heal, and then I don't see them any longer. So, I think, looking at the big picture, for me, is what I try to preach and what I try to get people to understand. How can you set a patient up for success, even if you do not have those resources? Who can you send the patient to in your area, and how can you set them up for success from an imaging perspective? Can you do anything for them offloading in the clinic that you're in? Can you get them set up with a podiatrist and get them to understand the importance of regularly following one, and how that podiatrist can really set them up for success in their future is what I believe and what the research shows. 

Physical therapists have a unique ability to not only look at the biomechanics of the foot, and adjust and personalize a treatment program for offloading. There are many, many options out there, and not just one option works for everyone, so finding someone in your area, whether it's a podiatrist or a physical therapist, someone who can be that person for the patient is important. 

Dr. Bojrab is a physical therapist who serves on the education steering committee for the Association for the Advancement of Wound Care. She has spoken at numerous conferences educating other providers on how to optimize treatment outcomes for the diabetic foot ulcer. She has recently transitioned into academia, where she is an Assistant Professor at the University of Indianapolis Krannert School of Physical Therapy.