Article

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.
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