All steps should be done with the patient in a prone position.

1. Preparation of the foot:

A. If an ulcer is present: debride ulcer as necessary. Apply dressing to ulcer. This is held in place with paper tape. No circumferential dressing is applied, as this would pose a risk of irritation to the skin or possible vascular compromise.

B. If the TCC is being applied for persons with Charcot and no ulcer, then no special dressing is required

C. Be sure that all toenails are debrided.

D. Skin is well hydrated, using emollient of choice.

E. Cotton or lamb's wool may be placed between the toes to reduce maceration.

2. Cotton stockinette is applied to the foot and leg.

A. Stockinette should be snug and form fitting.

B. Fold stocking over the toes dorsally and tape it in place.

C. Make a cut in the stockinette at anterior ankle and tape in place.

3. Apply a strip of 1/4 to 1/2 inch thick adhesive felt to the anterior aspect of the lower leg and foot. This should extend from tuberosity of tibia to the dorsum of the toes. As a modification to the traditional cast, one may place very thin adhesive moleskin on the medial and lateral aspect of the leg on the stockinette. This imparts minimal additional thickness or pressure, but protects the leg from inadvertent cast abrasions that may be caused when removing the cast.

4. Apply 1/4 to 1/2 inch thick adhesive felt (cut into oval or circle-shape) to the medial and lateral malleoli.

5. Apply a 4 inch square X 1 inch thick piece of foam across the tips of the toes and tape it in place.

6.  Apply a 4 inch X 5 yard roll of plaster extending from the toes proximally to the tibial tuberosity. It is very important that there be no tucks, bulges, or indentations in this layer of material.

7. Apply a roll of 3 to 4 inch fiberglass tape so as to cover the plaster.

8.  Apply two 4 inch fiberglass splints to the posterior aspect of the foot and leg. More fiberglass can be added to the posterior foot at this stage to accommodate for an equinus deformity and to the plantar medial aspect of the foot to accommodate for a varus deformity.

9. Wrap the cast from one end to the other (including the toes) with 1 to 2 more rolls of fiberglass.

10. The patient must then remain non-weight-bearing for 30 minutes. After this, a cast shoe may be applied to the casted leg to fortify the TCC construct and allow for limited ambulation.