Forefoot Offloading: Removable Cast Walkers Superior?!

This compelling study from our colleagues at Washington University in St. Louis, USA. 

In essence:
Forefoot offloading: RCW > TCC
Time to healing: RCW = TCC
Proportion of patients healing: RCW < TCC
Therefore: We might keep trying to make our devices less easily removable in neuropathic, non-infected, non-ischemic forefoot ulcers. 

Clin Biomech (Bristol, Avon). 2011 Apr 13. [Epub ahead of print]

Removable cast walker boots yield greater forefoot off-loading than total contact casts.


Applied Kinesiology Laboratory, Program in Physical Therapy, Washington University School School of Medicine, St. Louis, MO 63110, USA.



Elevated plantar loading has been implicated in the etiology of plantar ulceration in individuals with diabetes mellitus and peripheral neuropathy. Total contact casts and cast walker boots are common off-loading strategies to facilitate ulcer healing and prevent re-ulceration. The purpose of this study was to compare off-loading capabilities of these strategies with respect to plantar loading during barefoot walking.


Twenty-three individuals with diabetes, peripheral neuropathy, and plantar ulceration were randomly assigned to total contact cast (n=11) or removable cast walker boot (n=12). Each subject underwent plantar loading assessment walking barefoot and wearing the off-loading device. Analysis of covariance was used to compare loading patterns in the off-loading devices for the whole foot, hindfoot, midfoot, and forefoot while accounting for walking speed and barefoot loading.


For the foot as a whole, there were no differences in off-loading between the two techniques. Subjects wearing cast walker boots had greater reductions in forefoot peak pressure, pressure-time integral, maximum force, and force-time integral with respect to barefoot walking. Healing times were similar between groups, but a greater proportion of ulcers healed in total contact casting compared to cast walker boots.


In subjects with diabetes, peripheral neuropathy, and plantar ulceration, cast walker boots provided greater load reduction in the forefoot, the most frequent site of diabetic ulceration, though a greater proportion of subjects wearing total contact casts experienced ulcer healing. Taken together, the less effective ulcer healing in cast walker boots despite superior forefoot off-loading suggests an important role for patient compliance in ulcer healing.

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