**2. Foot ulcer treatment**

Foot ulcers are of managed by addressing infection, arterial disease and high forces in the foot. Infection is treated with antibiotics and debridement. Which antibiotic is determined by deep culture and, if needed, infectious disease consultation [30]. Vascular evaluation and treatment is recommended if the patient lacks both pedal pulses. Hyperbaric oxygen may a decrease the frequency of major amputations, but more studies are needed to confirm its causation in the decrease [31].

Off-loading consists of decreasing force in the foot. Forces in the foot can be decreased by tendon lengthening [27]. More ulcers than wound care and total contact casting (TCC) are healed by tendon lengthening [2, 24–26, 29, 32–39]. Tendon lengthening treatment of foot ulcers has good literature support [2, 24–27, 29, 33–41].

TCC, walking boots, and modified shoes helps heal foot ulcers [14]. However, TCC are difficult to apply, and has a higher complication rate and higher rate of recurrent ulceration than does tendon lengthening [32, 33]. Tendon lengthening removal of prominent metatarsal heads have similar results similar but with more transfer ulcers when only metatarsal head is removed [3].
