Our new paper is out today in Diabetology, and I’m really proud of this one. It’s a narrative review—co-authored with Bijan Najafi and Shervanthi Homer-Vanniasinkam—that traces the entire arc of offloading from the 1930s to right now. We called it “From Plaster to Pixels” because that’s genuinely what’s happened.
The story starts with Joseph Khan and Milroy Paul, who figured out in the 1930s that wrapping an insensate foot in plaster could heal ulcers—even without pain to tell the patient something was wrong. Then Paul Brand took that idea and turned it into the Total Contact Cast, giving us both a gold-standard tool and a biomechanical explanation for why neuropathic ulcers happen in the first place: repetitive moderate stress on weight-bearing areas. The insensitive foot breaks down not because of one catastrophic event, but because of the relentless drip of daily walking.
The problem, of course, was that TCC was a pain to apply and a pain to live in. By the 1990s, we knew it worked—but almost nobody was using it. That’s where the Instant Total Contact Cast came in. Larry Lavery and I, along with Andrew Boulton and others, showed that you could take a removable walking boot and simply make it irremovable with a wrap of cohesive bandage. Same healing rates as a traditional TCC. The magic wasn’t in the device—it was in forcing adherence. Patients wore their boots only about 28% of the time when they could take them off. Make it non-removable? Problem solved.
But “solved” is a strong word. Forcing people into a cast can feel punitive. And as our patients are living longer with diabetes complications, we’re seeing more frail individuals who simply can’t tolerate a knee-high non-removable device. We needed a different approach.
Enter the SmartBoot era. This is where the “pixels” come in. We’re now embedding sensors into offloading boots that track whether the device is actually being worn, count steps, monitor gait cadence, and stream it all to the cloud. The patient gets real-time nudges—a happy face on a smartwatch when the boot is on, a sad face when it’s off. The clinician gets a dashboard. It’s a shift from doing offloading to the patient to doing it with the patient.
The paper also digs into the latest meta-analytic evidence from Lazzarini, Bus, and our group—47 controlled studies showing that non-removable devices yield about 24% more ulcers healed than removable ones, that knee-high removable boots are no better than ankle-high ones (because patients don’t wear the bulkier ones), and that surgical adjuncts like flexor tenotomy can be real force multipliers for the right patient.
The core principle hasn’t changed since Khan’s plaster casts in 1939: take the pressure off. What’s changed is how we make sure that actually happens in real life. Technology doesn’t replace mechanical relief—it ensures the patient actually receives it.
The paper is open access—you can read the full thing here.
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