Many chronic wounds persist because of mechanical forces acting on the tissue. A venous leg ulcer will not heal if blood continues pooling in the lower leg, flooding the wound with protease-rich fluid that breaks down new tissue. A diabetic foot ulcer will not close if the patient keeps walking on it without redistribution of pressure away from the wound site.
Compression and offloading therapies address these forces directly. They are among the most evidence-supported interventions in wound care, and skipping them is one of the most common reasons chronic wounds fail to heal.
Compression
Compression therapy applies graduated external pressure to the lower leg, counteracting the elevated venous pressure that causes blood to pool, fluid to leak into surrounding tissue, and inflammatory enzymes to accumulate at the wound site.
Compression is not just a mechanical tool. It functions as a biologic therapy: by reducing ambulatory venous pressure, it improves lymphatic clearance, decreases protease-rich edema, and creates the conditions under which venous leg ulcers can actually heal.
We select from several compression systems based on your wound, your mobility, and your vascular status:
Multilayer compression wraps are the standard of care for most venous leg ulcers. They provide sustained therapeutic pressure between dressing changes.
Short-stretch bandages are suited for mobile patients or those with mixed arterial and venous disease who need compression that is active during movement but releases at rest.
Unna boots (zinc-impregnated wraps) provide semi-rigid compression and are particularly effective for highly exudative venous ulcers.
Compression stockings (20 to 40 mmHg) are used after wound closure to prevent recurrence. Without consistent post-healing compression, venous ulcers recur in up to 70 percent of patients within five years.
Velcro-based adjustable wraps are designed for patients with limited hand dexterity who cannot apply traditional stockings.
Intermittent pneumatic compression (IPC) devices are used as an adjunct for patients who cannot tolerate sustained compression or as additional therapy alongside wraps or stockings.
A critical safety requirement: Before any compression is applied, we perform a vascular assessment using the ankle-brachial index (ABI). An ABI of 0.9 to 1.3 supports standard compression at 30 to 40 mmHg. An ABI of 0.5 to 0.8 requires modified, lower-pressure compression (20 to 30 mmHg) with close monitoring. An ABI below 0.5 means compression is contraindicated, and the patient needs vascular referral for potential revascularization before compression can be safely used. Applying compression to a leg without adequate arterial blood flow can cause serious harm.
Offloading
Offloading is the practice of redistributing mechanical pressure away from a wound, and it is one of the most critical interventions for diabetic foot ulcers. Pressure above 32 mmHg collapses the microcirculation in tissue, cutting off the blood supply that the wound needs to heal. When a patient walks on an ulcerated area, the combination of perpendicular pressure and shear force (which doubles the rate of ischemic tissue damage) makes healing nearly impossible.
Total contact casting (TCC) is the gold standard for plantar (bottom-of-foot) diabetic foot ulcers. The cast redistributes weight across the entire foot, dramatically reducing pressure at the ulcer site. It also improves adherence because it cannot be easily removed.
Instant total contact casting (iTCC) wraps a removable cast walker with cohesive bandage to make it irremovable, achieving TCC-like pressure redistribution with a faster, less specialized application process.
Removable cast walkers (RCW) are effective when made irremovable. When left removable, patient adherence drops significantly, and outcomes suffer.
Custom orthotic insoles and rocker-bottom shoes are used after wound closure to prevent recurrence. For patients with recurrent ulcers, surgical offloading procedures such as Achilles tendon lengthening or metatarsal head resection may be considered.
Who It Helps
Compression therapy is indicated for patients with venous leg ulcers, chronic venous insufficiency, and lower-extremity edema that is contributing to wound stagnation. It is also used post-healing to prevent ulcer recurrence.
Offloading therapy is indicated for patients with diabetic foot ulcers, particularly plantar ulcers where weight-bearing pressure is a primary barrier to healing. It is also essential for pressure injuries in patients with limited mobility, where repositioning protocols and specialized support surfaces reduce tissue loading.
Both therapies require a thorough vascular assessment before initiation. Our team evaluates your arterial and venous circulation to determine which approach is safe and appropriate.
Your Visit
Here's what treatment typically involves.
For compression therapy, your clinician begins with a vascular assessment (ABI measurement) to confirm that compression is safe. The appropriate system is then applied in clinic. Multilayer wraps and Unna boots are typically changed once or twice per week at clinic visits. Between visits, you'll receive guidance on leg elevation, activity levels, and signs that require immediate attention.
For offloading, your clinician fits you with the appropriate device (TCC, iTCC, or RCW) and provides instructions on weight-bearing activity. Cast changes are performed at regular intervals, usually weekly, to assess the wound and adjust fit.
Both therapies are ongoing throughout the healing process. After wound closure, compression stockings or custom orthotic footwear become part of your long-term prevention plan. Premature withdrawal of compression is the single most common reason venous and diabetic ulcers recur.
For venous leg ulcers, compression stockings (20 to 40 mmHg) should be worn indefinitely to prevent recurrence. Without consistent compression, venous ulcers recur in up to 70 percent of patients within five years. Your clinician will help you find a system that fits your lifestyle.
It can be if applied without a proper vascular assessment. Compression on a leg with inadequate arterial blood flow restricts the limited blood supply the tissue depends on. That is why we perform an ankle-brachial index (ABI) test before starting compression and adjust the approach based on your vascular status.
Several alternatives exist, including Velcro-based adjustable wraps for patients with limited hand strength, intermittent pneumatic compression devices for patients who cannot tolerate sustained wrapping, and modified lower-pressure protocols for patients with mixed arterial and venous disease.
Pressure above 32 mmHg collapses the tiny blood vessels that supply the wound. Walking on a foot ulcer without offloading applies far more than that threshold, starving the wound of the blood flow it needs to heal. Offloading is one of the most evidence-supported interventions for diabetic foot ulcers.
For many diabetic foot ulcer patients, yes. Custom orthotic insoles and therapeutic footwear help redistribute pressure across the foot and reduce the risk of ulcer recurrence. Your clinician will discuss footwear options as part of your long-term prevention plan.
Request a consultation and let our team assess whether compression or offloading therapy should be part of your treatment plan.