Foot note The Netherlands

The MABAL shoe: our method for offloading plantar foot ulcers

Erik Manning, Ziekenhuisgroep Twente (ZGT), Almelo, the Netherlands.

In Almelo, we have a multidisciplinary diabetic foot clinic since the nineties. Based on our clinical experience and scientific studies, we developed the MABAL shoe for offloading plantar foot ulcers1-3.

The leading cause of plantar foot ulcers is increased plantar pressure, caused by limited joint mobility and foot deformities, in combination with a trauma or repetitive mechanical stress (improper footwear). Patients should be counselled never to walk in the same shoes that could have contributed to their foot ulcer.

The goal of treatment is redistribution of the load at the ulcer location to other regions of the foot. Different approaches are available, such as bed rest, felted padding, forefoot offloading shoes, prefabricated and custom-made casting devices. These methods all have their advantages and disadvantages. The most compelling evidence that off-loading accelerates ulcer healing comes from studies using a total contact cast. A disadvantage of the total contact cast is that the movement of the ankle joint is prohibited. This may cause joint stiffness, with muscle atrophy and bone demineralisation. As most ulcers occur in elderly patients, with a poor vision and limited joint mobility, a total contact cast may form an extra handicap during mobilisation.

To overcome these limitations, over a decade ago we developed the MABAL cast shoe. The MABAL cast shoe is a custom-made (moulded) ankle-high combi-cast shoe, worn with a roller-sole attached to the bottom of the cast. The complete mobility of the ankle joint allows the patient to be more ambulant, with a normal walking pattern. Patients can even go to work (see figure). This improves adherence.

Measurement studies show an average decrease of 48% peak pressure compared with 28% in a custom-made insole and 64% in a TCC1-3. We found healing percentages of 64% at 12 weeks and 85% at 20 weeks, which is comparable to published data of other removable modalities such1-3. Our clinical experience confirms that the MABAL cast shoe is an effective modality for offloading plantar neuropathic foot ulcers in patients with diabetes.

In conclusion, the MABAL cast shoe is an effective offloading device to treat a wide spectrum of diabetic plantar forefoot ulcers. It is easier to use than the use of a  total contact device, which improves patient adherence and mobility.

Foot note The Netherlands


1 – The MABAL shoe, an alternative method in contact casting for the treatment of neuropathic diabetic foot ulcers.
Hissink RJ, Manning HA, Van Baal JG.
Foot Ankle Int. 2000; 21(4):320-3.

2 – Plantar pressure in off-loading devices used in diabetic ulcer treatment.
Beuker BJ, van Deursen RW, Price P, Manning EA, Van Baal JG, Harding KG.
Wound Repair Regen. 2005; 13(6):537-42.

3 – The MABAL cast shoe for offloading plantar neuropathic diabetic foot ulcers: results from a 5-years retrospective analysis
Manning HA, Bus SA, Bril A, Van Baal JG.
Presented at the Diabetic Foot Study Group, Bratislava, 2014.

March 2015