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

Abstract

Background 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. Methods 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. Findings 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. Interpretation 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.

Comparison of the clinical effectiveness of different off‐loading devices for the treatment of neuropathic foot ulcers in patients with diabetes: a systematic review and meta‐analysis

“…The proportion of Wagner grade 1 and grade 2 ulcers in the study by Gutekunst et al . was not reported. The study by Agas et al .…”

Impact of strut height on offloading capacity of removable cast walkers

“…However, TCC are not commonly used in practice in the US, with only 1.7% of foot clinics using them as their standard offloading modality (Wu et al, 2008). Although RCW are used more commonly, they have been shown to provide poorer healing outcomes (Armstrong et al, 2001; Gutekunst et al, 2011). This is despite the fact that the two modalities provide nearly equivalent offloading (Baumhauer et al, 1997; Gutekunst et al, 2011; Lavery et al, 1996).…”

Preliminary Evaluation of a Cycling Cleat Designed for Diabetic Foot Ulcers

“…The peak pressure applied to the forefoot in the present study (10 kPa) during cycling with the specialized cleat was well below the values recorded in other studies that assessed loading during walking in offloading devices (66–134 kPa). 14,41 …”