The aim of this study is to compare the effectiveness of total contact casts based on wound location in groups of patients with diabetes mellitus with neuropathic ulcerations under the forefoot and patients with midfoot ulcerations associated with acute Charcot's arthropathy. Twenty-five consecutive diabetic patients with Meggitt-Wagner grade I neuropathic foot ulceration (NU) and 22 consecutive diabetic patients with neuropathic ulceration and acute Charcot's arthropathy (CU) were selected for study. Larger wounds took longer to heal in both the CU (p < 0.0001) and NU groups (p < 0.0001). Duration of ulcer prior to treatment also was significantly associated with increased healing time in both groups (p = 0.008 NU, p = 0.03 CU). The CU group had larger wounds (10.3 +/- 4.6 vs 7.7 +/- 4.0 cm2, p = 0.04) but took significantly less time to heal (28.4 +/- 13.0 vs 38.8 +/- 21.3 days, p = 0.04) than did subjects with neuropathic ulcerations only. The NU group had their ulcers present for a significantly longer period of time prior to contact casting (88.5 +/- 98.3 vs 17.7 +/- 12.9 days, p = 0.001). In this study, subjects with ulcerations secondary to acute Charcot fractures healed more rapidly than in previous reports with healing times of forefoot neuropathic ulcers similar to previous studies. Every patient's ulcer healed. There were no cast-related ulcerations, infections, or hospitalizations. Concerns regarding the safety of total contact casts to treat well-vascularized superficial forefoot and midfoot plantar wounds appear to be unfounded.