In the neuropathic foot, the ulcer is managed by off-loading, by which means there is a redistribution of load bearing on the plantar surface of the foot. The most efficient way is by the immediate application of some form of cast, including the removable cast walker such as the Aircast Walker, the Scotchcast boot and the total contact cast (21). The Aircast is a removable bi-valved cast. It is lined with four air cells, which can be inflated with a hand pump to ensure a close fit. The Scotchcast boot is a simple removable boot made of stockinet, felt and fibreglass tape. The total contact cast is a close fitting plaster cast applied over minimum padding. It should be reserved for plantar ulcers that have not responded to other casting treatments (28). It is also useful in patients with recurrent foot ulceration (29). Nonremovable fibreglass casts have been also used (30).
Recently, standard removable cast walkers have been modified by wrapping plaster around them to make them nonremovable and to increase patient compliance. This is just as successful in healing diabetic foot ulcers as the total contact cast (31). If casting techniques are not available, accommodative sandals such as half shoes can off load the site of ulceration. A recent study showed that total contact cast healed a higher proportion of wounds in a shorter time than the removable cast and the half shoe (32).
In the neuroischemic foot, a high street shoe that is sufficiently long, broad and deep and fastens with a lace or strap high on the foot to reduce frictional forces on the vulnerable margins of the foot may be sufficient. Alternatively, a ready-made stock shoe, which is wide fitting, may be suitable.
Heel ulcers can be off-loaded by a foam wedge or pressure relief ankle-foot orthosis (PRAFO), which suspends the heel to protect against further breakdown and allow the ulcer to drain. The PRAFO has a washable fleece liner with an aluminium and polyproprylene adjustable frame and a nonslip walking neoprene base (33).
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