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

David J. Gutekunst, Mary K. Hastings, Kathryn L. Bohnert, Michael J. Strube, David R. Sinacore

Research output: Contribution to journalArticlepeer-review

37 Scopus citations


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.

Original languageEnglish
Pages (from-to)649-654
Number of pages6
JournalClinical Biomechanics
Issue number6
StatePublished - Jul 2011


  • Diabetes mellitus
  • Off loading
  • Peripheral neuropathy
  • Plantar pressure
  • Plantar ulcer
  • Removable cast walker boot
  • Total contact cast

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