Think Before You Total Contact Cast

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Total contact casting (TCC) is the treatment gold standard for healing plantar diabetic foot ulcers, but is it right for everyone? 

The answer is no. 

In my practice, this is not because of patient noncompliance or the lack of experience in applying a cast, but rather patient physical limitations, namely - the inability for a patient to safely ambulate in a TCC.

By far, the biggest conundrum that I face when deciding to place a patient in a TCC is whether or not they can walk in this device safely and without falling.  The single most common reason why I discontinue TCC treatment is due to patient falls

Can your patient safely walk in a total contact cast without falling? – Karen Shum, DPM

Not only is sensory neuropathy prevalent among patients with diabetic foot ulcers, but so is motor neuropathy.  The longer a patient has diabetes, the more likely a patient will develop poor proprioception and balance.

Unfortunately, I have had patients experience falls at home where they end up calling emergency services to help them off the floor at home.  Other patients have ended up with fractures while in a TCC.

TCCs can be cumbersome for some patients.  It adds weight and height to the limb, thereby causing limb length discrepancy, altered gait, and imbalance.  This is a recipe for falls and the problem becomes magnified in the elderly or those who have severe motor neuropathy.

Careful consideration should be made to determine whether or not a TCC is the most appropriate offloading device for patients.  So what is my protocol for recommending a TCC?

A fall risk assessment is done for each and every patient before beginning a Total Contact Casting program

A fall risk assessment is done for each and every patient who presents to my office. I ask if they have fallen within the last year. I check whether or not they initially present with an ambulatory aid such as a cane or walker. Their gait is also evaluated as well as their mental status. If any one of these findings is confirmed, then I refrain from putting on a TCC.

Another subset of patients with balance problems are those with contralateral limb loss.  Patients who use a below knee or above knee prosthesis are also not ideal candidates for TCC.