Total Contact Casting
Reviewed by Andrew Schox, BSc(Hons) PGradDipPod MPod, October 2026
A total contact cast (TCC) is a close-fitting cast, usually from your toes to your knee, that touches your whole foot and shares your weight with your leg. It is mainly used to heal foot ulcers on the underside of the front or middle of the foot in people with diabetes and nerve damage. Because you can't easily take it off, the ulcer stays protected. It is applied by a trained clinician, changed about weekly, and may be needed for many months. It isn't suitable if you have an infection, severe swelling or severe poor circulation.
What is it?
A total contact cast (TCC) is a close-fitting cast that is usually applied from your toes to your knee. It touches your whole foot, which is where the name comes from. This spreads your weight across your foot and up your leg, so the ulcer (an open sore) carries less pressure.
The key feature is that you can't easily take it off. That keeps the pressure off the ulcer all the time, including when you would rather not wear it. An offloading device (anything that takes pressure off a sore) only works if it is worn.
A TCC has to be applied by a trained clinician. It also comes with trade-offs for how you move, wash and sleep.
What is it used for?
The main use is healing ulcers on the underside of the front or middle part of the foot in people with diabetes and neuropathy (nerve damage that dulls feeling). Guidelines recommend a cast that can't be removed and reaches the knee as the first choice for these ulcers. A total contact cast is one such device. A non-removable walking boot is the other.
There is some support for casts that can't be removed in ulcers with mild infection or mildly reduced blood flow, although your team will assess this carefully. For ulcers on the top or side of the foot, under the heel, or with more serious infection or poor circulation, there is very little to go on.
A TCC is also used for Charcot foot (an inflammatory condition that affects the bones and joints in people with diabetes and nerve damage), for broken bones in the foot, and for wounds after foot surgery. How well it works for these isn't clear, so the decision rests on your clinician's judgement.
Is it right for me?
A TCC suits a non-infected ulcer on the underside of the front or middle of the foot in a person with diabetes, when the ulcer needs pressure taken off to heal.
It isn't suitable if you have:
- an infection in the soft tissue of the foot
- an infection in the bone
- severe poor circulation
- severe swelling of the lower leg or foot
Poor circulation needs special care. With mild to moderate poor circulation, a cast may still be possible, depending on blood pressure tests at the ankle and toe. Healing is slower when circulation is poor. If you have signs of infection, severe swelling or poor circulation, get it assessed before any cast is put on, and don't delay that.
If a cast that can't be removed doesn't suit you, or you can't manage it, a removable device that reaches the knee or ankle is the second choice. Tell your team if you are unsteady on your feet, have poor mobility, or think you won't cope with the cast.
What happens?
Your circulation and the ulcer are checked first. The podiatrist also removes hard skin and dead tissue around the ulcer, because these can hide the ulcer and slow healing.
Applying the cast usually takes about 20 to 30 minutes. Some cast systems are quicker.
You are usually seen about once a week. At each visit the cast is taken off, your foot is checked, and a new cast is put on if needed. Early on it may be changed at one- or two-week intervals, so it doesn't become loose as the swelling goes down. Treatment may last many months, and sometimes over a year. How many casts you will need isn't clear in advance, so ask your podiatrist how it is going at each visit.
Between visits:
- Check the cast every day, or ask someone to check it for you. Reduced feeling in your foot can hide problems.
- Keep the cast dry.
- Don't push objects or powder down inside the cast.
- Don't dry it with a hairdryer.
- Don't try to remove it yourself.
How well does it work?
Casts that can't be removed heal more ulcers than removable devices, special therapeutic shoes, or dressings alone. A total contact cast and a non-removable walking boot work equally well.
A main reason is thought to be that you can't take the cast off. Adherence (wearing the device as prescribed) strongly influences healing. Removable walkers are easier to use and let you check the ulcer more often, but they are easy to take off, so they are often worn less.
Healing takes time. In a total contact cast, ulcers at the front of the foot healed in about 91 days on average, and ulcers in the middle or back of the foot in about 75 days. In a removable walker, the same ulcers took about 132 days and 102 days. Healing is slower in people with poor circulation.
Risks and side effects
The main problems are infection, skin that goes soft and sodden under the cast (maceration), and skin scrapes (abrasion). The cast can also rub and cause new sores elsewhere on your foot or leg. If you have nerve damage you may not feel this, which is why daily checks matter. Skin irritation can happen too, and you can't see the ulcer every day.
Other things to plan for:
- Falls: The cast makes you less steady. Walk less, use crutches, and use a walking frame if you were already unsteady.
- Hip or back pain: The casted leg is longer than the other, so walking too much can strain your hip or back.
- Sleep: The cast can rub your other leg at night. Wear a thick, soft knee-high sock on that leg.
- Pressure sores: A small number of people at high risk are more likely to get them, especially with a cast that covers the knee. Reposition your leg about every two hours.
- Blood clots: Wearing a cast can raise the risk of a clot in a leg vein (deep vein thrombosis) or in the lung (pulmonary embolism).
- New heel ulcers: Adding an operation to lengthen the Achilles tendon (the large tendon at the back of your ankle) to a cast has limited value for front-of-foot ulcers. It may cause more new heel ulcers than a cast alone.
The warning signs to act on are listed under "When to see a podiatrist".
Afterwards
Keep attending every cast change. At each visit, ask how your ulcer is changing and what the plan is if it isn't getting better. If the ulcer isn't progressing in the cast, your circulation should be checked again. If offloading without surgery doesn't heal a front-of-foot ulcer, your team may discuss surgery, such as lengthening the Achilles tendon or operating on the bones or joints at the front of the foot.
What you do alongside the cast matters too. Controlling your diabetes, cholesterol and blood pressure, stopping smoking, doing more cardiovascular exercise (exercise that gets your heart pumping) and managing your weight all reduce the risk of serious problems with a diabetic foot ulcer.
When to see a podiatrist
When to book
Book an appointment with your podiatrist if you have a diabetic foot ulcer and want to know whether a cast that can't be removed suits you, if you are unsteady on your feet or think you won't cope with it, or if your ulcer isn't getting better in the cast so it can be reviewed.
When to get help sooner
Call your local emergency number if you suddenly become short of breath, have chest pain (especially pain that is worse when you breathe in), or cough up blood. If you have a foot ulcer and you also feel very unwell, with confusion or slurred speech, severe shivering or muscle pain, severe breathlessness, mottled or discoloured skin, or little or no urine, this could be sepsis: call your local emergency number. The following need urgent medical assessment: new or increased pain or swelling in your calf or thigh (a blood clot can form in a leg wearing a cast); a fever, flu-like symptoms, a temperature above 38.3 °C or below 36 °C, or a heart rate above 90 beats per minute; or a cast that is loose, tight, dented, cracked, soft, wet or smelly, with discharge or blood staining, rubbing or pain, swelling, a change in skin colour, or painful, swollen or blue toes, which can be signs of infection. Contact your podiatrist or foot team straight away. If you can't reach them, or it is out of hours, see your GP today, or go to an urgent care clinic or the nearest emergency department rather than wait. If your ulcer has discharge or a new smell, contact your foot team, podiatrist or GP within 24 hours. If you have signs of infection, severe swelling or poor circulation before a cast is put on, get assessed first and don't delay.
Frequently asked questions
Can I shower or bathe with the cast on?
No, bathing isn't allowed with a cast you can't remove, and the cast has to stay dry. A wet or soft cast is a warning sign to report to your foot team. Ask your podiatrist how to wash while you are casted.
Can I drive, and will I need time off work?
Don't drive while you are wearing the cast. You also can't drive a manual car while casted. Weekly clinic visits for cast changes, and treatment that can last many months, may mean time off work. Talk with your podiatrist early about your job and how to get around.
Is it worth the effort if treatment takes months?
Healing is the goal, and sticking with the cast helps it happen. Among people with diabetic foot ulcers, amputation was more common in those whose ulcers didn't heal (39.1 per cent) than in those whose ulcers healed (3.1 per cent). This shows a link, not that one causes the other.