Total contact casts are rigid casts that extend from the foot to below the knee, maintaining full contact with the plantar surface of the foot and lower leg. They immobilize joints and soft tissues while allowing ambulation. Total contact casts are considered the gold standard for offloading diabetic foot ulcers and Charcot joints. They work by redistributing weightbearing forces, decreasing edema and shear forces, localizing infection, and protecting the wound and foot. Precautions must be taken with padding and monitoring for adverse effects like iatrogenic ulcers. Recent advances include removable walkers that convert to total contact casts.

1. TOTAL CONTACT CAST
Dr Joe Antony
MD(Physical medicine and
rehabilitation)
KGMU,Lucknow

2. INTRODUCTION
Total contact cast is rigid or semi-rigid molded cast which extends
from the patient’s foot to just below the knee, maintaining contact
with the entire plantar surface of the foot and lower leg and
immobilizing surrounding joints and soft tissue while allowing the
patient to remain ambulatory.
Considered as gold standard of offloading techniques
Started in early 1930s as a treatment modality for post hansens
neuropathic ulcer
Effective , Rapid and ambulatory
ARMSTRONG DG, NGUYEN HC, LAVERY LA, VAN SCHIE CH, BOULTON AJ, HARKLESS LB: OFF-LOADING THE
DIABETIC FOOT WOUND: A RANDOMIZED CLINICAL TRIAL. DIABETES CARE. 2001;24(6):1019–1022.
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3. MATERIALS USED
Soft Padding
Only minimal padding
Padding specially on malleoli , tibial shaft and ulcer
Plaster of Paris
Fibreglass Plaster
Rubber sole
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4. METHOD OF APPLICATION
Thorough cleaning of wound and applying a thin layer of moisturizer over normal skin
Application of padding- thin layer all around with some extra padding on ulcer, malleoli and shin
Application of two layers of Plaster of Paris with extremely close moulding of all arches, curves and prominences
Design is reinforced with a layer of fiber glass
An extra layer of fiber glass applied on plantar aspect to give rigid sole ( a rubber sole can also be applied
MESSENGER G, MASOETSA R, HUSSAIN I. A NARRATIVE REVIEW OF THE BENEFITS AND RISKS OF TOTAL CONTACT CASTS IN THE MANAGEMENT OF DIABETIC FOOT ULCERS. J AM COLL CLIN WOUND
SPEC. 2018 JUN 7;9(1-3):19-23. DOI: 10.1016/J.JCCW.2018.05.002. PMID: 30591897; PMCID: PMC6304285.
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5. MECHANISM
Redistributes weightbearing forces,
Decreases edema
Protects the wound and surrounding tissues
Decreases sheer forces
Localizes infection
Protects the foot from outside contaminants,
Provides immobilization of the wound and Charcot joint.
BRADDOMS TEXTBOOK OF PHYSICAL MEDICINE 5

6. INDICATIONS
Neuropathic ulcers of foot
Charcot's joint – early stage and advanced stage
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7. CONTRAINDICATIONS
Infective wounds
High exudate wounds
A bivalve TCC can be considerd
Malignant ulcers
BRADDOMS TEXTBOOK OF PHYSICAL MEDICINE
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8. BENEFITS
Maintain the ambulation while maintaining offloading
Low cost
Readily available raw materials
Reduces dressing cost
Forced Compliance
Armstrong et al (2003) studied the usage of removal walker with in built accelerometer to find out –
only 28 % percent of ambulation is done wearing removable walker by an average patient
Mueler et al(1989) concluded Neuropathic ulcers heals typically in six weeks in
total contact cast
MUELLER M.J, DIAMOND J.E, SINACORE D.R, ET AL. TOTAL CONTACT CASTING IN TREATMENT OF DIABETIC PLANTAR ULCERS. CONTROLLED CLINICAL TRIAL. DIABETES CARE . 1989;12(6):384–388. PMID:
2659299
. ARMSTRONG DG, LAVERY LA, KIMBRIEL HR, NIXON BP, BOULTON AJ: ACTIVITY PATTERNS OF PATIENTS WITH DIABETIC FOOT ULCERATION: PATIENTS WITH ACTIVE ULCERATION MAY NOT ADHERE TO A
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9. DEMERITS
Cannot use in infection or ischemia
Recent studies suggest we can use total casts in mild infection also.
Challenge to take a bath
Prevents from driving or traveling
Need compensatory foot wear other side
BRADDOMS TEXTBOOK OF PHYSICAL MEDICINE
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10. ADVERSE EFFECTS
Iatrogenic Ulcerations
Guyton GP et al ( France,2005), did a study on 398 casts and found iatrogenic
ulcerations are only 5.5%
Study also concluded that Iatrogenic ulcerations heal earlier than primary ulcer.
Deterioration of primary ulcer
Extremely rare
Due to
Poor patient selection
Poor padding and moulding
Prolonged use ---> Muscle atrophy and Reduced bone density
GUYTON GP: AN ANALYSIS OF IATROGENIC COMPLICATIONS FROM THE TOTAL CONTACT CAST. FOOT ANKLE
INT. 2005;26(11):903–907.
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11. PRECAUTIONS
Padding to protect bony prominence.
Patients advised to check for signs of discoloration of exposed toes,
swelling, or signs of bleeding.
Contralateral leg should be protected from injury by TCC by
covering with long socks or a pillow cover while in bed.
Cast should be protected from getting wet
Prevent Leg length discrepancy and thereby postural instability by
avoiding making unnecessarily thick plaster sole
Or use Shoe balancers for contra lateral limb
Gait rehabilitation program- To reduce muscle atrophy and loss of
bone density
MESSENGER G, MASOETSA R, HUSSAIN I. A NARRATIVE REVIEW OF THE BENEFITS AND RISKS OF TOTAL CONTACT CASTS IN THE MANAGEMENT OF DIABETIC FOOT ULCERS. J AM
COLL CLIN WOUND SPEC. 2018 JUN 7;9(1-3):19-23. DOI: 10.1016/J.JCCW.2018.05.002. PMID: 30591897; PMCID: PMC6304285.
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12. LATEST ADVANCES IN TCC
Removable below knee walker converting to TCC by applying
Fiberglass roll over it
TCC-EZ® System
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13. THANK YOU
REFERENCES
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2. AAOS Atlas of orthosis and Assistive devices
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7. Mueller M.J, Diamond J.E, Sinacore D.R, et al. Total contact casting in
treatment of diabetic plantar ulcers. Controlled clinical trial. Diabetes Care
. 1989;12(6):384–388. PMID: 2659299
8. Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ,
Harkless LB: Off-loading the diabetic foot wound: a randomized clinical
trial. Diabetes Care. 2001;24(6):1019–1022.
9. Messenger G, Masoetsa R, Hussain I. A Narrative Review of the
Benefits and Risks of Total Contact Casts in the Management of Diabetic
Foot Ulcers. J Am Coll Clin Wound Spec. 2018 Jun 7;9(1-3):19-23. doi:
10.1016/j.jccw.2018.05.002. PMID: 30591897; PMCID: PMC6304285.
10. Cakar E, Durmus O, Tekin L, Dincer U, Kiralp MZ. The ankle-foot
orthosis improves balance and reduces fall risk of chronic spastic
hemiparetic patients. Eur J Phys Rehabil Med. 2010 Sep;46(3):363-8. Epub
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Acknowledgements
• Dr Madhumita S Roy
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