Ten Tips for a great cast

1. Always take a full weight-bearing tracing of both feet on a flat, hard surface. This acts as an important check for the length of the last and shows the true orientation of toes, amputation sites, etc. 

2. Seat the patient so that his feet rest firmly on the floor. You want to get some weight-bearing to ensure that you capture the true length and width of the forefoot. 

3. If the patient has a normal range of motion at the ankle, cast the foot with the lower leg at 90 degrees to the ground. In cases where there is severe equinus, leg-length discrepancy, or rigid ankle, cast the patient in the position of function, and mark the vertical alignment on the cast and Rx form. 

4. Tell the patient that you are trying to capture the shape of the functioning foot so that he understands to not constrict his toes or remove the downward pressure. 

5.  If the patient is subject to edema, it is best to cast him later in the day when the foot and ankle are most swollen.

6. If the patient wears a permanent AFO, brace, gauntlet, or compression stocking, take the cast while he is wearing the device. However, be mindful that some orthotic devices, stockings, and wound dressings are for short-term use only, thus potentially affecting the long-term fit of the shoe! 

7. Place a 1/2" - 1" soft foam cushion under the foot in order to allow the contours of the arch and heel to come out in the cast.

8. Use a casting board with a 1/2" - 3/4" pitch under the heel. This will create some plantarflexion and help ensure that the toes are not dorsiflexed in the cast.

9. The plaster "clam-shell" or "bivalve" techniques and the newer casting socks are the best methods to capture the full foot with all intricacies and contours. Try to avoid "wrap" techniques when casting the foot. They can often be too tight and will poorly reveal the definition and true length of the toes. Although they can be the cleanest and quickest (at the time!), fiberglass wraps result in the most problems.

10. Before you cut or remove the cast, score the surface with some pencil lines to show the correct alignment