Summary

A total of 522 pieces of literature were found from all searches. Fifty-one pieces of information were included in the final scoping review as detailed in Table 1. All of the included information addressed both conditions and included at least one of the management strategies of interest. Some of the literature discussed more than one strategy. A summary of the searching and screening process is displayed in the PRISMA flow diagram in Fig. 1. Publications that did not discuss the situation where diabetic foot ulceration and lower limb oedema present concurrently, was the most common reason for exclusion at both the title and abstract screening (n = 378, 88%) and full text screening (n = 24, 59%) stages.

Table 1 Key management strategies identified from included literature with level of evidenceFig. 1

PRISMA flow diagram for the scoping review process [10, 17]

Literature characteristics

The included literature spanned a date range of 24 years (1998 – 2022). It was produced from 13 different countries with the UK (n = 21, 41%) and USA (n = 10, 20%) being the most prevalent. 44 pieces of literature came from a published source (86%) and seven from unpublished sources (14%). Literature considered to be higher in quality such as evidence-based summaries and guidance, evidence synthesis and research studies [18] were fewer in numbers (n = 21, 41%). Foundational resources and unpublished literature which is considered to be lower in quality [18], was higher in numbers (n = 30, 59%). Details for evidence type can be viewed in Table1.

The majority of the included literature related to the use of compression therapy as a strategy to manage lower limb oedema where a DFU is present (n = 24, 51%). There was less information available regarding off-loading strategies (n = 13, 25%). Only three pieces of literature discussed the use of both an off-loading and compression therapy strategy simultaneously (6%). Nine pieces of literature solely focused on a supplementary strategy (18%), although 16 supplementary strategies were identified in total across all of the included literature. Details for these results can be viewed in Table1.

Off-loading strategies recommended or contraindicated in the treatment of a DFU for people who also have lower limb oedema

The off-loading strategies to treat a DFU in those with lower limb oedema, mapped against the review objectives, can be viewed in Table 2. Total contact casting in the presence of lower limb oedema was most frequently discussed in the literature (n = 5) [1, 41,42,43,44]. This type of cast was described to primarily treat a diabetic foot ulcer by immobilising the foot and ankle and off-loading pressure from the wound area. However, appropriate use where lower limb oedema is present appeared uncertain. One retrospective cohort study [41], found that oedema was a contributory factor to adverse events in those receiving treatment for a DFU, such as the development of a new wound, infection, pain or discomfort requiring cast removal. The study found the patient population most prone to complication was those with "neuropathy and limb volume fluctuation due to both venous insufficiency and vasomotor lymphoedema”. Yet another piece of literature also suggests that the firm outer casing of the cast could be used to prevent or reduce oedema [42], although the author acknowledges that their suggestion is anecdotal. Peripheral neuropathy [43], osteomyelitis [2, 41, 44], soft tissue infection/cellulitis [2, 41, 43, 44] and varicose veins [44] were suggested contraindications across all of the literature.

Table 2 Information identified for off-loading strategies and mapped against review objectives

Six pieces of literature discussed the use of removable walking casts or boots as detailed in Table 1. All of the literature agrees the primary purpose is to off-load pressure from the wound area [27, 45,46,47,48,49]. Four publications, discussed knee-high devices, of which one author advocates using the ridged nature of a knee-high device to act in reducing limb volume [45]. Yet other information advises that such a device should protect the limb from further damage by accommodating oedema rather than reducing it [46, 47]. The remaining two publications discussed the use of an ankle-high device. One case study [49] describes how a removable ankle boot was used to allow for the use of compression bandages. However, specific indications and contraindications or adverse effects were not reported.

A back-slab casting technique [49] and a Scotchcast™ boot [28], were described in two pieces of literature to treat DFU. However, there was insufficient information to determine whether these strategies could be used with oedema management strategies.

The remaining two strategies found, included an off-loading shoe [50], which is intended to be used with off-loading insoles and a heel reliever [51], used to treat a DFU occurring at the heel when a person is in the prone position. Both devices state they are designed to accommodate oedema, but not suitable for those with associated complications of oedema such as leg ulcers or lymphorrhoea.

Compression therapy strategies recommended or contraindicated to manage lower limb oedema where a DFU is present

Compression therapy strategies to manage lower limb oedema where a diabetic foot ulcer is present, mapped against the review objectives, can be viewed in Table 3. This scoping review found eleven pieces of information across all of the literature, suggesting that compression bandaging was an effective way to reduce and manage oedema (as detailed in Table 1 and 2), which additionally could have beneficial effects on the healing of DFU [16, 19,20,21,22,23,24,25,26, 29, 40]. One scoping review [16] was found which explored the effect of compression bandaging on the healing of DFU. Compression bandaging was deemed to be safe in those without severe arterial compromise. Several case studies were found [19, 21, 22, 24, 26], all describing challenging examples where DFU management was complicated by lower limb oedema. A change was made to usual care, by introducing compression bandaging to reduce oedema and achieving a more positive outcome. Two further case studies [27, 49] also introduced an offloading intervention to treat plantar DFU in addition to compression therapy. All of the literature reported a positive change to DFU outcomes but none gave suggestions for contraindications or reports of adverse incidence.

Table 3 Information identified for Compression therapy strategies and mapped against review objectives

The review found 10 pieces of information across all of the literature which suggests that compression hosiery or wrap systems could be useful in managing lower limb oedema where a DFU is present [1, 20, 27, 28, 30,31,32,33,34,35] (Tables 1 and 3). A prospective study [30], and a 12-week, double blind, randomised controlled trial [31] were found, whose studies used participants with diabetes, with and without mild to moderate peripheral arterial disease, to test the safety of compression hosiery. Both studies also reported that compression hosiery was safe in the absence of severe peripheral arterial disease. However, participants with larger wounds, copious amounts of exudate and infection were excluded, suggesting their use was not considered suitable for larger, more complex wounds.

The use of pneumatic compression systems to manage lower limb oedema and improve healing of DFU was found in the literature and further suggests that it may be used even where severe peripheral arterial disease or non-revascularisable conditions are present [34, 36,37,38,39]. However, two publications cited supporting studies which acknowledge that their sample sizes were small and studies were of low methodological quality [38, 39].

Supplementary strategies identified from the review

The identified supplementary strategies to manage a DFU and lower limb oedema where both conditions present together, and mapped against the review objectives, can be viewed in Table 4. A total of 16 supplementary strategies were identified across all of the included literature (Table 4).

Table 4 Information identified for supplementary strategies and mapped against review objectives

Integrated working, where multiple conditions such as DFU and oedema management may require input from multiple teams, was the most frequently mentioned supplementary strategy(n = 5) [20, 25, 52,53,54] and was one of the suggestions which could be applied to any clinical situation. However, this particular suggestion, despite its inclusion in two national guidance documents [52, 53], is referenced as based on expert opinion rather than scientific study. A similar suggestion is made by two best practice statements [54, 55], also based on expert opinion, which recommend that treatment plans should be specifically tailored to meet the individual needs of patient to maximise treatment quality. A clinical review piece [56] and a conference abstract [57] were found discussing the use of specifically designed wound and limb assessment and triage tools. Both tools acknowledged lower limb oedema as a risk factor to diabetic foot ulcers and suggest they could be used as a prompt to encourage oedema management as part of DFU treatment, further encouraging tailored treatment plans and integrated working.

Other suggested supplementary strategies included: Patient education [58], leg elevation [2, 20, 58, 59], elbow crutches [45, 49], exercise [25, 27, 60], weight control [20, 60], manual lymphatic drainage [1, 25], bed rest [27], skin care [25], neuromuscular taping [61], pharmacological [60] and surgical options [62]. The evidence to support these supplementary interventions came from foundational sources including case studies, literature reviews and expert opinion pieces which are considered to be of lower evidential quality [18].