Rathur H, Boulton A. Pathogenesis of foot ulcers and the need for offloading. Horm Metab Res. 2005; 37:61-68

Frykberg RG, Lavery LA, Pham H Role of neuropathy and high foot pressures in diabetic foot ulceration. Diabetes Care. 1998; 21:(10)1714-1719

Pham H, Armstrong DG, Harvey C. Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial. Diabetes Care. 2000; 23:(5)606-611

Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care. 1998; 21:(5)855-859

Armstrong DG, Nguyen HC, Lavery LA Off-loading the diabetic foot wound. Diabetes Care. 2001; 24:(6)1019-1022

Cavanagh PR, Bus SA. Off-loading the diabetic foot for ulcer prevention and healing. J Vasc Surg. 2010; 52:37S-43S

Wunderlich RP, Armstrong DG, Husain K, Lavery LA. Defining loss of protective sensation in the diabetic foot. Adv Wound Care. 1998; 11:(3)123-128

McCluskey S, Gooday C. A holistic approach to the management of a neuropathic plantar ulcer. J Wound Care. 2008; 17:(4)167-170

Consensus development conference on diabetic foot wound care. Diabetes Care. 1999; 22:(8)1354-1360

International Working Group on the Diabetic Foot. International working group on the diabetic foot: specific guidelines on footwear and off-loading. Treatment of ulceration: offloading. 2007. (accessed 16 November 2012)

Brem H, Sheehan P, Boulton AJ. Protocol for treatment of diabetic foot ulcers. Am J Surg. 2004; 187:(5)S1-S10

Faglia E, Caravaggi C, Clerici G Effectiveness of removable walker cast versus non-removable fiberglass off-bearing cast in the healing of diabetic plantar foot ulcer. Diabetes Care. 2010; 33:(7)1419-1423

Wu SC, Jensen JL, Weber AK Use of pressure offloading devices in diabetic foot ulcers. Diabetes Care. 2008; 31:(11)2118-2119

Spencer S. Pressure relieving interventions for preventing and treating diabetic foot ulcers. Cochrane Database Syst Rev. 2000; (3)

Coughlan M, Cronin P, Ryan F. Step-by-step guide to critiquing research. Part 1: quantitative research. Br J Nurs. 2007; 16:(11)658-663

Armstrong DG, Lavery LA, Nixon BP, Boulton AJ. It’s not what you put on, but what you take off: techniques for debriding and off-loading the diabetic foot wound. Clin Infect Dis. 2004; 39:S92-S99

Myerson M, Papa J, Eaton K, Wilson K. The total-contact cast for management of neuropathic plantar ulceration of the foot. J Bone Joint Surg Am. 1992; 74:(2)261-269

Burns J, Begg L. Optimizing the offloading properties of the total contact cast for plantar foot ulceration. Diabet Med. 2011; 28:(2)179-185

Caravaggi C, Faglia E, De Giglio R Effectiveness and safety of a nonremovable fiberglass off-bearing cast versus a therapeutic shoe in the treatment of neuropathic foot ulcers: a randomized study. Diabetes Care. 2000; 23:(12)1746-1751

Beuker BJ, van Deursen RW, Price P Plantar pressure in off-loading devices used in diabetic ulcer treatment. Wound Repair Regen. 2005; 13:(6)537-542

Lavery LA, Vela SA, Lavery DC, Quebedeaux TL. Reducing dynamic foot pressures in high-risk diabetic subjects with foot ulcerations. A comparison of treatments. Diabetes Care. 1996; 19:(8)818-821

Shaw JE, Hsi WL, Ulbrecht JS. The mechanism of plantar unloading in total contact casts: implications for design and clinical use. Foot Ankle Int. 1997; 18:(12)809-817

Gutekunst DJ, Hastings MK, Bohnert KL. Removable cast walker boots yield greater forefoot off-loading than total contact casts. Clin Biomech. 2011; 26:(6)649-654

Armstrong DG, Lavery LA, Kimbriel HR Activity patterns of patients with diabetic foot ulceration. Diabetes Care. 2003; 26:(9)2595-2597

Lavery LA, Baranoski S, Ayello EA. Options for off-loading the diabetic foot. Adv Skin Wound Care. 2004; 17:(4)181-186

Greenhalgh T. How to read a paper: the basics of evidence-based medicine.Oxford: Wiley-Blackwell; 2006

Nabuurs-Franssen MH, Sleegers R, Huijberts MS Total contact casting of the diabetic foot in daily practice. Diabetes Care. 2005; 28:(2)243-247

Katz IA, Harlan A, Miranda-Palma B A randomized trial of two irremovable off-loading devices in the management of plantar neuropathic diabetic foot ulcers. Diabetes Care. 2005; 28:(3)555-559

Piaggesi A, Macchiarini S, Rizzo L An off-the-shelf instant contact casting device for the management of diabetic foot ulcers. Diabetes Care. 2007; 30:(3)586-590

Armstrong DG, Short B, Espensen EH Technique for fabrication of an ‘instant total-contact cast’ for treatment of neuropathic diabetic foot ulcers. J Am Podiatr Med Assoc. 2002; 92:(7)405-408

The total contact cast: controversy in offloading the diabetic foot

02 December 2022
Volume 6 · Issue 4


Total contact casting has long been considered the gold standard for offloading the diabetic foot. However, it remains underutilised with less than 2% of clinicians reportedly using it for the treatment of the majority of diabetic foot ulcers. Proper TCC application with avoidance of iatrogenic lesions requires skilled cast technicians, trained in casting the insensate foot, and is an expensive and time-consuming process. Additionally the TCC is contraindicated in patients with infection or critical ischaemia and must be used with caution in elderly patients, those with visual or equilibrium problems, those with a contralateral foot ulcer or with varicose veins.

There is minimal robust evidence for the use of the TCC over other offloading modalities such as the removable cast walker and the instant total contact cast. However there is also minimal evidence for iatrogenic lesions caused by TCC. Additionally, the superior offloading properties and expedited healing rates of the TCC are demonstrated in a number of smaller studies. In conclusion there is a lack of consensus on the best device to offload DFU. However offloading is undoubtedly paramount to successful and timely healing. More research with larger samples sizes is required to support the TCC as the gold standard off loading device.

Diabetic foot ulceration (DFU) represents a major medical, social and economic problem globally. While more than 5% of diabetic patients have a history of foot ulceration, the cumulative lifetime incidence may be as high as 15% (Fig 1).1

Diabetic foot ulceration. The cumulative lifetime incidence may be as high as 15%

Retrospective and prospective studies have shown that elevated plantar pressure is a cause of the development of plantar ulcers in diabetic patients,2,3 and that ulceration is often a precursor of lower extremity amputation.4 The central goal of any treatment plan designed to heal plantar ulcers, is effective reduction of pressure (offloading).5 In the sensate foot, for example in a patient with rheumatoid arthritis, offloading pressure at painful regions of the foot is both driven and evaluated by the patient’s pain.6 However, up to 50% of patients with diabetes will eventually develop neuropathy and loss of protective sensation.7 Sensory neuropathy, coupled with deformity secondary to autonomic and motor neuropathy, makes offloading the diabetic foot a considerable challenge.8

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