Intermittent

Claudication
Early peripheral arterial disease (PAD) commonly presents as claudication, a term
derived from the Latin claudico meaning to limp. (Ward, 1998) Intermittent
claudication is described in the literature as a transient, exercise induced ischemic
myalgia characterized by aching, cramping, tiredness, or tightness of the affected
muscle compartment (Ward, 1998). The calf being the most commonly effected
(Ward, 1998). When normal muscles are exercised , metabolic by-products are
released resulting in relaxation of smooth muscle in the arterioles, venules and precapillary sphincters. The resistance in these vessels greatly decreases. Since blood
flow is inversely proportional to resistance, blood flow to the healthy exercising
muscle will increase 10-20 times and thus meet the increased metabolic demands
of that muscle, removing the noxious metabolic end products (Ward 1998).
When an individual with significant organic occlusion participates in exercise,
relaxation of the smooth muscle in the arterioles, venules and pre-capillary
sphincters still occurs, a problem arises due to the fact that the occluded vessel is
narrowed and uneven due to plaque deposition. The amount of blood that is able to
pass this occlusion per unit time is greatly limited, the end result being that the
demand of the exercising muscle is not met. Pain is felt when the accumulation
metabolic by-products within the muscle is at high enough concentrations to
activate pain receptors, more exercise results in more pain. Once the individual
stops exercising, the rate of metabolism within the muscle decreases, the blood
flow to the muscle can then wash away the high levels of metabolites and the
individual will then achieve symptomatic relief (Ward, 1998).

The locality of pain usually correlates with the location of the occlusion, pain is
usually perceived one segment distal to the obstruction, i.e., toe pain usually
reflects an occlusion in the midfoot, calf pain an occlusion in the knee or distal thigh
and so forth (Hoffman 1992). It is important to correlate the patients history with
the physical findings and to clearly identify whether the patients pain is of
ischaemic origin, and to exclude any differential diagnoses. Ischemic pain is worse
during exercise and is located in muscles, whereas arthritic pain is located in joints,
the patient whos pain is of ischaemic origin is more likely to suffer earlier onset of
symptoms when walking up hills. Pain of neurologic origin probably correlates with
back pain and is noticed in specific positions (Hoffman. 1992). If the patients main
presenting complaint is more severe at rest and the patients ABPI is greater than
0.8, the pain is not likely to be of ischemic origin. It is important to ascertain and
note how far the patient can walk before requiring rest, this allows a semiquantitative measure for future inquiries, it is also important to enquire as to any
changes/progression the pain has made since it was first noticed.

An introduction to manufacturing EVA orthoses, and use

of other moldable thermoplastics

There are many different materials available for use in the fabrication of orthoses,
and the ability to choose an appropriate material for devices is as important as any
other prescription variables within the device.
There are circumstances where the most effective treatment of a patient will include
exerting an influence on gait and plantar pressures during stance phase. Some of
these circumstances will involve conditions where a rigid cast orthosis is not a
practical solution. Factors that effect the path of action can include the desires of
the patient, the cost of the various treatment options, the symptoms and diagnosis
of the patients condition and the primary underlying causes of the presenting
complaint. This is not an attempt to outline issues such as this in any
comprehensive way, but rather an indicator that much thought and consideration of
options should precede any action.
There are circumstances where a practitioner may be unable to aim for what they
believe is the theoretically correct or best answer because of issues relating to

patient compliance, extremes of activity by patients or complicating health issues

related to disease processes and many other confounding problems. These factors
are real but should not discourage the practitioner from their best efforts in
attempting to solve problems and improve quality of life for patients.
There are times when significant improvement in patient comfort can be achieved
using plantar pressure spreading methods with the use of materials that are much
softer than the materials used for cast rigid devices.Sometimes a patient may be
unable to tolerate the more rigid materials and the medium density foams may offer
both pressure relief and comfort.
There are many different semi-rigid and soft materials available that are heat
mouldable at fairly low temperatures. Their physical properties vary greatly and the
desired set of characteristics will vary depending on each circumstance.
Consideration of patient activities, specific conditions, desired outcomes and other
factors will be required. In general terms the softer materials will exert a less
specific effect on gait. When choosing materials bear in mind the age and body
weight of the patient. The 90 to 250 density materials tend to be better for children
and where a more comfort oriented solution is sought for adults. The 300 to 450
density EVA'S are really quite hard and are used as posts for rigid orthoses so when
using these it can be important not to effect the foot too aggressively.
Commonly used and cost effective materials include Ethylene Vinyl Acetate (EVA) ,
Plastazote, "polydorane" (which seems to be Smith & Nephew Easy cast with the
appropriate heating curve), and blown polypropylene. This is not meant to be a
comprehensive list of options but is an attempt to encourage students to
experiment with a variety of materials that will increase the range of solutions
available to their patients in the future.

EVA
The common forms of EVA foam are pressure blown (nitrogen gas) closed cell foams
with small cell sizes. It is available in a range of densities (varying Young's Modulus
of compression). Common densities are rated according to how many kilograms
they weigh per cubic metre. The normally available densities include, but are not
restricted to 45, 90, 120,220,270,350 and 400kg per metre cubed. To get a feel for
these it is best to mold and grind and actually wear/use them yourself to begin to
understand what results you can achieve with each different density.
There is very little published information in relation to this subject. However there is
a clinical history of positive feed back from patients and practitioners over many
years. A suggested reading list will be offered at the end of this piece that may help
encourage students to follow this area up a little more. More definite insights will no
doubt arise as research in biomechanics and orthoses of a variety of types
continues. The author has no doubts about the reality of benefits/improvements
that are possible. The key is to stay focused on doing the best job you can for each
patient and be encouraged by the positive feedback that will follow.
Construction of non- rigid devices is an iterative process where the first attempt
may not be the best and patient feedback is crucial to a final approach to the best
answer for any given individual. It must be borne in mind that there are many
patients out there for whom a complete resolution of symptoms is not possible,
particularly in the area of rheumatoid arthritic conditions. This should not
discourage you from making the best of the situation for the patient through
palliative load spreading methods.

Immediately after vacuum pressing

Immediately after rough grinding

Web Resources

Click here for a link to a lecture from

the University of Western Sydney,
discussing the material properties of
orthoses.

Langer Biomechanics (a large orthoses lab in the USA - information

about products, services and some biomechanical information)

PFOLA (Professional Foot Orthoses Laboratories of America information about the organisation)
ISB Footwear Biomechanics (International Society of Biomechanics abstracts and articles pertaining to previous and upcoming
conferences and seminars looking at footwear biomechanics)
Orthopaedic Topics (knock yourself out! - lots of information)
Superfeet (manufacturer of orthoses for a range of sporting
applications)
Rieckens Orthotic Laboratory (another orthoses lab in the USA)

Manufacturing EVA orthoses: a basic guide

The Manufacturing Process

First decide which density or densities of EVA are apropriate based on patients'
weight, uses and degree of effect wanted.
Prepare suitable sized pieces and laminate them together with contact adhesive.
Heat flat blanks until they are soft - not burnt. See for yourself and your oven how
long this takes.
Have a piece of 1.5 to 3 mm Poron (or sox) available to protect your patient from
the heat of materials during direct molding.

Click here for a

more vertical view of
the Jetronic molding
system

Quickly set the patient up on soft blanks on top of the chosen molding pillows using
protective layer on top of hotter materials.
The second
method pictured
is a partial weight
bearing system
using a molding
box with tightly
stretched rubber
membrane over
which the heated
blanks are placed
and the a seated
patient pushes
their feet into the
soft blanks.

While waiting for the material to cool it pays to draw a suitable heel cup border in
with a biro (and an outline of the toes on full length devices). This is not always
necessary, but you can't do it later if the patient leaves while you finish off the
grinding. Always leave full length devices long until actually fitting to the patients
footwear.

The grinding process requires

excess material to be removed
from both lateral and medial
sides. It works better if these
borders are fairly straight, but
angled to the sagittal plane to
facilitate shoe fitting (see
pictures below).
Click here for a detailed view
of grinding the medial border
of an EVA device

The heel cup needs to be finished so as to fit the footwear concerned but a good
generic shape is pictured. A common problem is too much material left under the
heel for the device to easily fit in shoes. The finishing process should use a
diferential grind height for heel and forefoot similar to finishing a rigid orthosis (see
below). This seems to allow a better seating of the finished article in footwear. Heel
height should finish somewhere between about 14 and 22mm after the plantar
surface of the heel has been ground thin (approx 3 mm).

Posterior view
of ground EVA
device. Note the
angulation of
the medial and
lateral grinds
relative to
vertical.

When grinding the forefoot, note that

When grinding the plantar heel, note that
the plantar heel surface is 4mm above
the forefoot is 4mm (with an average heel
the forefoot . The brown spacers seen
pitch - this can vary between shoes
above elevate the heel for forefoot grind,
depending on heel height) below the plane
and are removed to allow the plantar heel
of the grinding surface.
grind.
The forefoot can be finished
to incorporate features such
as a valgus wedge or
Dananberg style Kinetic
wedge which leaves a device
that is all in one piece and
easy to accomodate within
footwear. To achieve a variety
of features the devices can be
ground from the plantar
surface to vary the thickness
of material left under the
foot.
In the picture on the left,
note the valgus forefoot
wedge that has been ground
into the device.

The process of adding a smaller

and denser rearfoot post or
stabiliser is simple. Cut the
desired small piece and cover
with glue, and place in oven to
soften. Cover place on
previously molded first layer
(when cool) with glue and then
laminate by hand when the small
piece is soft. Some grinding may
be required for aesthetics and to
facilitate shoe fitting.

EVA devices can also be

made using plaster casts
in the usual vacuum
press manner as for rigid
orthoses. It could be
argued that this allows
for more precise results
and control of the foot
during casting. Plaster
additions can be made to
the foot in the same or
different ways as is
performed for rigid
orthoses.
It is possible to use a simple foam block under the patients' foot for the molding
process and this will work, however manufactured molding pillows are relatively
inexpensive (~ $140) and have a long lifespan so the acquisition of a pair is
justified if you intend to do this frequently. Heating of materials can be done in a
small toaster oven that costs as little as ~$110 and it has been known to be done
with a hot air gun .

Direct molding can be done to the foot of a prone patient however the speed and
convenience of weighted or partial weighted molding makes these options fairly
good ones. The method pictured here is a commercially available system
incorporating preformed molding pillows, a heating drawer and a" podoscope" that
gives a rudimentary view of the pattern of weight bearing of the plantar aspects of
the feet.

Cost Issues
The question of benefit versus cost to the patient or cost to the taxpayer remains
an issue. It suffices to say that with practice and familiarity these direct molded
devices can be made during one 30 minute consultation from materials ranging in
cost from as little as $5 through to approximately $40. For the cost of a
consultation and materials the patient may end up with a product with a life span of
years that offers significant improvement in comfort. It is worth emphasizing
that speed of production is a significant issue in relation to keeping costs
down for the patient and this speed depends on a willingness to practice.
Speed can also be improved by use of prefabricated, two dimensional blanks that
are precut and just need to be molded and finished off. These save time and effort
and are offered in quite a variety of forms in a range of materials.
It is also worth mentioning that these types of devices can significantly improve
sporting performance in the medial edging sports such as snow skiing, roller
blading and ice skating. (See Langer Laboratory orthoses web site and others).
Grinding and finishing can be performed with any standard grinder. 80 or 100 grit
silicon paper works fine for all these materials. They all have slightly different
grinding characteristics but again practice solves any problems.

Occupational Health and Safety Issues

The main issues are eye protection, ear protection and lung protection. Solutions to
these problems are fairly obvious : wear your protection
The particle size produced when grinding is the major factor as far as inhalation
danger goes. Some materials produce relatively large particles (30 microns) which
don't float around in the air so well and do get filtered out by grinder suction
systems. Some materials throw much smaller particles (under three microns) and it
is particles in this range that are much more dangerous. Most grinders come with
filter systems that filter down to only about 30 microns, so all the fine stuff gets
blown out through the bag for you to inhale. The most cost effective solution is to
have an external exhaust because industrial systems that filter down to ~1 micron
start at about $5000. There are small HEPA (high efficiency particulate air) filters
on the market from ~$250 that can greatly improve air quality in small spaces
(good for fungal spores in treatment rooms) but don't hook up directly to grinders.
Further information on workplace safety is available from the Victorian government
WorkCover department.
Less obvious issues include the potential toxicity of glues and solvents. Toluene
which features in some contact cements can have serious effects on some people at
lower levels than historically predicted. It's not just when you are grinding that
you need to be careful.. Allergenic reaction to materials can also occur.

Web Resources

Click here to view an illustrated

guide to manufacturing a simple
template for use in non-cast
insoles (from the University of
Western Sydney website).

Introduction to EVA
Orthoses
Phillip Carter

An Introduction to the Total Contact Cast & Ambulatory

Fibreglass Boot
The following webpages include information about two types of
rigid casting used in podiatry - the Total Contact Cast (TCC) and
the Ambulatory Fibreglass Boot (AFB). Below is an introduction to
the significance in treating foot ulceration, with indications,
contraindications, advantages, disadvantages and patient
instructions for each. Linked to this page are comprehensive
pictorial guides to application of each of these casts.
Total Contact Cast Application
Ambulatory Fibreglass Boot Application
Introduction
Diabetes Mellitus is a common disease affecting more than 350 000 Australians in
1990 and is estimated to affect 900 000 Australians by the year 2000. Diabetes
Mellitus is a condition that has both personal and public health implications. On an
individual level Diabetes Mellitus may have enormous emotional, social and
economical and physical effects on the individual. Payne &Scott (1997) estimated
the annual total inpatient cost for diabetic foot disease in Australia to be $48 - $53
million indicating that Diabetes Mellitus is a financial dilemma for the public health
system.
The treatment of diabetic foot ulcers has been a difficult task for Podiatrists and
other health professionals in the past. The introduction of Total Contact Casting and
Ambulatory Fibreglass Boots as a method of neuropathic ulcer treatment has
allowed effective short term healing of plantar wounds by effectively reducing
mechanical stresses and pressures on the plantar surface of the foot. Total Contact
Casts and Ambulatory Fibreglass Boots allow the patient to be ambulatory and
reduces lengthy and expensive hospital costs associated with complete bed rest,
nursing care and lower limb amputations. These treatment methods also allow the
patient to maintain employment, so there is no income loss for the individual.

Over the years there has been a lot of research undertaken that investigates the
effectiveness of Total Contact Casts in the treatment of neuropahtic ulcers. The
results in Table.1 prove that the Total Contact Cast reduces the healing rate of
neuropathic ulcers. The average healing time from the studies examined is 6.1
weeks. Similarly, the Ambulatory Fibreglass Boot has also shown to reduce healing
rates of neuropathic lesions in some cases. However, unlike the Total Contact Cast
little research has been conducted using this method of treatment. The average
healing time for Ambulatory fibreglass Boots taken from the literature available is
10.7 weeks (Table .1). This has lead researchers to believe that the Total Contact
Cast may be the treatment of choice for neuropathic ulcers.

TOTAL CONTACT
CAST (TCC)

Borssen and Lithner

(1989)

Gilbey (1991)

Diamond, Mueller &

Delitto (1993)

HEALING
AMBULATORY
HEALING
RATES (mean healing FIBREGLASS BOOT RATES (mean healing
time
(AFB)
time)

10 weeks

4 weeks

6 weeks

Birke, Novick,
Coleman, Patout
6 weeks
(1991).
Unpublished research.

Walker, Helm &

Pullium (1985)

Boulton, Bowker,
Gadia, Lennerman,
Caswell, Skyler,
Sosenko (1986)

Burden, Jones, Jones

& Blandford (1993)
3 months

Gilbey (1991)
Jones (1990)
(Good diabetes
control;
HbAlc 7% or less)

4-6 weeks

6.1 weeks

Jones (1990)
(Poor diabetes
19.8 weeks
control;
HbAlc 7.1% or more)

4.4 weeks
(Forefoot ulcers)

6 weeks

Sinacore, Mueller,
6.2 weeks
Diamond, Blair, Drury
& Rose (1987)
Table 1: Average healing rates of neuropathic ulcers using TCC & AFB.

THE TOTAL CONTACT CAST

The aim of the Total Contact Cast is to immobilise the foot in order to reduce the
vertical forces during gait thus allowing the plantar ulcer or pre-ulcerous lesions to
heal. Total Contact Casts also promote healing by controlling lower leg and foot
odema and protecting the foot from trauma. (Kominsky 1994).
INDICATIONS FOR TOTAL CONTACT CAST
1. Plantar neuropathic ulcers.
2. The post-operative surgical foot.
3. Active Charcot neuropathic foot.
CONTRAINDICATIONS FOR TOTAL CONTACT CAST
1. Active or acute soft tissue infection.
2. Abcesses, osteomyelitis & gangrene.
3. Ulcer depth greater than ulcer width.
4. Fragile skin
5. Excessive leg or foot swelling
6. Patient unwilling too have cast on extremity
7. Patient unable to comply with follow-up visits
8. Blind
9. Obese
10. Ischaemia ulcers with a doppler pressure < 0.4
11. Patients prone to falls have an increased risk of falling due to the Limb length
discrepancy created by the cast.
12. The cast creates a limb length discrepancy which may possibly induce hip and
back pain.
(Sinacore, 1988)
ADVANTAGES
1. Reduces healing time of plantar ulcers.
2. Allows patient to maintain ambulation.
3. Reduces excessive plantar pressures.
4. Protects foot from further trauma.
5. Controls odema.
6. Allows patient to continue working.
7. Cost effective.
8. Doesn't require as regular changing compared to other modalities.
(Sinacore, 1988)
DISADVANTAGES
1. Cast cannot be removed.
2. Unable to visually assess for infection or ulcer progress until cast is removed.
3. Joint stiffness and muscle atrophy if immobilization is prolonged
4. Possible skin abrasion or new ulcerations if cast is poorly applied or not
monitored
5. Possible foul odour if drainage is excessive.
6. Digital fungal infections due to moist environment in cast.
7. Possible complications due to undiagnosed osteomyelitis after cast is applied.
(Sinacore, 1988)
Total Contact Cast Application
PRECAUTIONS

Thorough training and practice in cast application is required to ensure success and
to reduce possible complications associated with immobilizing an insensate foot.
"Skill in plastercraft is not to be learned from books but only by continuous
repitition..One who regards the application of plasters as a menial task is advised to
transfer his attention to another speciality" - John Charnley (1950)
The key to minimising potential side effects is strict monitoring of the ulcer,
observing the patient's tolerance to the cast and most importantly careful
application of the Total Contact Cast. Unless the patient is willing to comply with
regular follow up visits casting should not be implemented.
(Sinacore, 1988)
PATIENTS INSTRUCTIONS
The patient must be supplied with a thorough list of written instructions on how to
look after the cast and what complications to look out for whilst wearing the cast.
These include;
1. Walk as little as possible. This will put less pressure on the wound thus allowing
it to heal faster.
2. The leg with the cast will be longer than the other leg therefore this may put
strain on the hip and back if you walk too much.
3. You will be less stable when wearing the cast so the chances of falling are
increased. The less you walk the less likely you are to fall. Be careful on slippery or
uneven ground.
4. You may wish to use a walking stick for added stability. If you were unsteady
before the cast you should use a walker.
5. The cast must not get wet. Take sponge baths instead of normal bathing or
showering.
6. Notify the Podiatrist or General Practitioner if any of the following occur;
Any loosening or excessive mobility of the foot in the cast. A space of more than _
inch between the cast and leg is too much.
A smell coming form the cast may indicate infection that started after the cast was
put on.
Any sudden tenderness in the inguinal lymph nodes.
Any sudden increase in body temperature, fever or blood sugar levels.
Any pain or discomfort.
Any dents, cracks or other damage to the cast. These may apply dangerous levels
of pressure to the leg/foot.
Any drainage on the outside of the cast, particularly in regions not adjacent to the
ulcer.
Excessive swelling of the leg or foot, causing the cast to become too tight.

THE AMBULATORY FIBREGLASS BOOT (SCOTCHCAST BOOT)

The aim of the Ambulatory fibreglass Boot is to redistribute foot pressures over the
entire surface area of the sole of the foot thereby removing direct pressure from
the wound site. It has proven to be effective in treating neuropathic wounds in
some cases however as previously mentioned there has been little published
research into the healing times associated with its use.

INDICATIONS FOR THE USE AMBULATORY FIBREGLASS BOOT

1. All types of neuropathic ulcers.
2. Neuropathic ulcers under the 1st metatarsal head and those under the hallux
respond
well to this treatment. Ulcers under the lesser metatarsal heads also respond well
to
treatment. The heel is the most difficult to treat.
3. Mixed neuropathic/ischaemic ulcers may be treated with Ambulatory fiberglass
boots however the degree of ischaemia will be the limiting factor as to whether this
treatment can be used.
CONTRAINDICATIONS FOR THE AMBULATORY FIBREGLASS BOOT.
1. Ambulatory fibreglass boots are unsuitable for ulcerations which are wider than
they are deep. If the ulcer is deeper than it is wide the surface of the ulcer may
epithelialise before the base of the ulcer has time to heal. The premature closing of
the ulcer would leave a cavity beneath the skin, increasing the potential for abscess
formation.
(Kominsky 1994)
2. Certain dorsal and digital ulcers which are inappropriate due to their location.
3. If the patient has an Ankle/Brachial Index (ABI) of 0.35 or less or is diabetic and
has an ABI of 0.45 or less then this treatment is contra-indicated as these ulcers
will
probably not heal. (Wilson 1991).
ADVANTAGES
1. Redistribution of foot pressures.
2. Custom built to suit the individual.
3. Rigid and lightweight.
4. Removable for redressing, bathing and sleeping.
5. Patient remains ambulatory.
6. Decreased healing time according to literature.
7. Ability to assess progress of the wound.
8. Inexpensive compared to hospital costs.
(Wilson 1991)
DISADVANTAGES
1. Unaesthetic, bulky and hot
2. Expensive
3. May require an orthotic and possibly specialist footwear.
4. Requires specialist application and therefore is not suitable for every clinical
situation.
5. Minimal use on digital ulceration.
6. Contra-indicated in cases of ischaemia.
7. Difficult to walk in due to the limb length discrepancy the cast creates.
8. May increase the instability of patient therefore increase the number of falls.
(Wilson 1991)
Ambulatory Fibreglass Boot Application

PATIENT INSTRUCTIONS
1. Patients should refrain from vigorous activities which could interfere with healing
of the ulcer or cause fractures in the cast due to its lightweight, strong and water
resistant properties.
2. Patients may swim, bathe or shower when clinically indicated.
3. Patients should be cautious against accumulation of foreign materials such as
sand under the cast. Foreign objects may cause further irritation and cause other
ulcerations to develop or cause infection of the existing ulcer if bacteria enters the
wound.
4. If the cast becomes wet it should be dried with towels or a hair dryer if
necessary.
5. Prolonged or frequent wetting of the cast without drying may produce macerated
skin. This is the most frequent complication noticed with the Ambulatory fibreglass
boot. (Albert, 1981).

Application of the Total Contact Cast (TCC)

|

Return to Casting
Introduction

Ambulatory Fibreglass Boots

application

Some of the materials used in the cast application process

1. Prepare the foot

A. Debride toenails
B. Rehydrate skin with emollient
C. Place cotton between toes to
absorb moisture.
D. Debride ulcer as necessary and
apply light dressing. (Ulcer must be
wider at the surface than it is deep).

2. Apply sockinette to the leg.

A. Sockinette must be firm with no
wrinkles.
B. Fold sockinette dorsally over the
toes, and tape it in place.
C. Make a cut in the sockinette at
the ankle joint level and seal it with
tape.
Please note that in the following
photographs, the foot has been
placed in a more plantarflexed
position than it should be for this
cast- the foot should be
approximately at a right angle to the
leg.

3. Apply a 3-inch wide strip of 7mm

adhesive felt to the anterior aspect
of the leg.
Bevel the edges of the felt well. The
felt must extend from the dorsum of
the toes to
the tibial tuberosity.

4. Cut two circular pieces of felt

large enough to cover and protect
both malleoli, then
tape in place. Bevel edges well.
A piece of 4-inch foam is taped
across the tips of the toes from the
dorsum to plantar
surface of the foot.

5. Apply a 4-inch roll of plaster of

paris to the foot and leg so that it
extends from the
base of the toes to the proximal
extent of the felt.
Care must be taken to eliminate all
bulges and folds of plaster, especially
on the bottom of the foot.
Hold the foot at 90
degrees to the leg. Be sure to only
use the flat surfaces of the hands
and avoid using
fingertips.
6. Several layers of plaster of paris
are applied to the bottom of the foot
so it is perpendicular to the long axis
of the leg. This create a
rockerbottom sole aiding propulsion
during ambulation.
Alternatively, a 4-inch piece of
plywood may be
applied to the sole of the foot to
create the rockerbottom.

7. Apply a 3-inch roll of fibreglass to

the foot covering the plaster of paris.
Apply
evenly and avoid bumps and sharp
edges.
A rubber walking heel may be placed
on the sole of the foot just proximal
to the
metatarsal heads (optional).
Complete the rest of the cast with 3inch roll of fibreglass, covering the
foam over the toes. One to two more
rolls of material are usually used at
this point.

8. The patient is required to remain

in the office for approximately 30
minutes to allow for drying and to be
sure that the fit is acceptable.
When the cast is ready for changing
a cast saw is used to remove the
cast. The cast should be cut along
the anterior border of the cast where
there is felt padding protecting the
leg.

Return to Casting
Introduction

Ambulatory Fibreglass Boots

application

Application of the Ambulatory Fibreglass Boot

(Scotchcast Boot)
Emily Carpenter, 1998
Total Contact Cast application | Introduction to Casting

1. Sockinette is applied
to the lower third of the
leg, extending 10cm
beyond the toes.

2. Mark the lesion.

Apply felt padding to
remove pressure from
the wound site.

3. Using 7mm semicompressed felt cut a

slab to cover the sole
of the foot so that it
extends up both sides
of the foot and the
heel.
Use additional 5mm felt
for valgus fillers or
wedges if required. Cut
a window in the felt if
required.

4. Wrap a strip of 5mm

x 7-10cm wide felt or
sponge rubber around
the ankle for malleolar
protection and secure
with micropore.

5. Hold the felt slab

securely in place with
two rolls of 10cm
Softban. Evenly
distributed over the
whole area. Mark the
lesion if necessary.

6. Apply one roll of 2

inch fiberglass from the
toes to the ankle. Apply
the remaining 3 inch
roll from the ankle to
the toes.
Be sure to rub the
fiberglass well to get a
smooth finish.
REMEMBER TO ALWAYS
WEAR GLOVES.

7. It is important to get
the patient
weightbearing in a
normal stance position
to facilitate ambulation
- it is best to stand on a
piece of foam or similar
to prevent sticking to
the floor.
8. Once the cast is dry
mark the lesion and
cutting lines.

9. Using a plaster saw,

bi-valve the cast on the
dorsum and trim to the
required height and
length. Remove the bivalve.

10. Cut the sockinette

and turn the sockinette
back over the ankle
and toes and secure
with 3 inch extension
plaster.

11. Remove cast from

the foot and seal the
cut ends of the padding
using 3 inch Extension
plaster.

12. Apply a rubber

sponge strip along the
dorsum of the foot and
ankle.

14. Apply a 3 layer

slab of fiberglass on the
sole of the foot to
create a rockerbottom
sole.

15. Wrap another roll

of fiberglass around the
foot from the toes to
the ankle.

16. Mark the bi-valve

on the dorsum of the
foot and cut with a cast
saw.

17. Cover the edges of

the cut fiberglass with
extension plaster so
there is no sharp
corners
Refit the boot to the
foot and hold firmly in
place. A tongue pad of
felt helps to add
comfort and firmness.

18. Use a Post-Op

walking shoe at all
times when
weightbearing. The
cast can be removed
and replaced as
necessary for dressing,
bathing and sleeping
etc.