What Is Serial Casting and How Can It Help My Child?

Physical Therapy, Serial Casting

Quick Summary

Serial casting is a non-surgical treatment that uses a series of casts, changed about once a week, to gradually stretch tight muscles and improve a child’s joint range of motion. It’s most often used for toe walking. Treatment length varies by child, and your physical therapist will guide the plan. Westside Children’s Therapy offers serial casting at select clinics. Find a casting location.

Wondering if it’s the right time to start? Read 5 Reasons to Start Serial Casting.

What is serial casting?

Serial casting is a non-invasive, conservative treatment used to gradually improve the range of motion in a joint. It works through a series of casts applied over time, each one adjusted to gently stretch tight muscles and tendons a little further than the last. Because it’s non-surgical, it offers a lower risk way to restore movement, and it can be applied to any extremity joint in both the upper and lower body. 

The most common use is to help correct toe walking, a pattern where a child walks on the balls of their feet with little or no contact between the heel and the ground. In that case, casting gradually lengthens the tight muscles at the back of the lower leg so the child can move toward a more typical heel-to-ground step. Whatever the joint, the goal is the same: steady, lasting improvement in how freely it moves. 

Ankle Range First session (before serial casting) vs. Ankle Range (after serial casting) Final Session

How is serial casting different from a regular cast?

The main difference between serial casting and regular casting is the purpose and the process. A regular cast generally holds a body part in a fixed position to protect an injury and allow it to heal. A serial cast uses a sequence of casts to gradually increase joint range of motion and lengthen tight muscles or soft tissues. For example, if a child has tight calf muscles and can’t bring the ankle up far enough, a serial cast can improve the range of motion. The first cast holds the ankle at the maximum comfortable position. After several days, the cast may be removed, and a new cast is applied with the ankle positioned slightly farther towards the desired range. This process is repeated until the targeted range of motion is reached. 

Why do children need serial casting? 

Children may need serial casting when a joint or muscle has become tight, limiting normal movement and interfering with physical development. It is often used as a non-surgical way to gradually improve flexibility and function. People commonly use it for persistent toe walking, to manage neuromuscular and genetic conditions, adapt to rapid growth spurts, or improve the fit of braces or orthotics¹. 

Serial casting for toe walking

While toe walking is common among toddlers, especially under the age of two, it becomes a serious problem when it persists between ages three and four. Over time, walking continuously on the balls of the feet can tighten the calf muscles or Achilles tendon. 

Serial casting increases the ankle’s ability to move upward, allowing the child to bring the heel closer to the ground while walking. During the treatment, a cast holds the ankle in a gently stretched position. After several days, the therapist removes the cast and replaces it with a new one that may position the ankle slightly farther into dorsiflexion. The tissues are gradually stretched so the child can start walking in a heel-to-toe pattern.  

Other conditions that may benefit from serial casting

Other conditions that serial casting helps improve include the following²: 

• Cerebral palsy: Treatment may improve range of motion when spasticity causes muscle tightness or contractures. 
• Neuromuscular conditions: It can also help manage flexibility limitations associated with altered muscle tone or weakness. 
• Congenital and pediatric deformities: Infants born with structural bone deformities or joint misalignments can also benefit from early intervention. 
• Post-injury stiffness: In selected cases, casting may help restore movement after an injury.

Serial casting is often one part of a larger plan. Depending on your child’s needs, the team may also recommend occupational therapy or speech therapy. Toe walking is also seen in some children with autism. If you have other developmental questions, our autism screening and guide to the early signs of autism can help you decide on next steps. To learn more about why casting is commonly recommended for toe walking, read Toe Walking in Kids: Why Serial Casting Is Often Recommended.

How does serial casting work? 

Over the course of wearing the cast, typically changed weekly, a prolonged and progressive stretch occurs until the desired range of motion is reached. Unlike a broken bone, where immobilization is the goal with a cast, serial casting encourages movement and staying active. The casts are applied in a way that the child feels comfortable, other than the minimal weight of the cast.

The duration of serial casting depends on the severity of range lost, diagnosis, and age. Older children will typically wear casts longer because their muscles have tightened and are used to their limited range of motion. 

Depending on the stiffness of the joint, children can see gains of 2 degrees to 8 degrees per week for a total treatment time of 4 weeks to 6 months. You can ask your therapist for a personalized estimate. 

In addition to increasing the range of motion, it also puts the child in a safer position to bear weight on their heels on different surfaces. It will also allow them to shift weight properly and increase independence in standing and walking. 

What happens during a serial casting appointment?

Your child will have their cast changed weekly, and progress will be recorded. The casts will be removed to take measurements and photos. Post-casting videos of a child’s walk will also be taken to track their progress. 

During casting sessions, children will lie on their belly for about one hour per cast. Your child should wear loose-fitting clothing that can be rolled up during the session. 

Step 1: Evaluation

Before casting, your child’s therapist evaluates their range of motion, muscle tone, strength, walking pattern, posture, and everyday movements. For children who toe walk, this includes checking for tightness in the calf muscles or Achilles tendon. The evaluation is tailored to your child’s condition and helps determine whether serial casting is appropriate and how to approach treatment.

Step 2: Measurements

Your child’s therapist measures the joint’s range of motion to establish a baseline before casting. For ankle casting, this may include checking how far your child can flex their foot upward with the knee straight and bent. These measurements guide the initial cast position and help track progress throughout treatment.

Step 3: Cast application

Your child’s therapist protects the skin and gently positions the joint at its maximum comfortable range before applying the cast. The cast holds the joint in place to provide a sustained stretch without significant pain. For children who toe walk, casting gradually brings the ankle into a position that helps the heel make better contact with the ground.

Step 4: Progress monitoring

Your child’s therapist closely monitors their progress throughout treatment to determine what adjustments are needed for the next cast. At each visit, they assess your child’s comfort, skin condition, circulation, movement, and range of motion to understand how well your child is responding to treatment and guide the next steps.

The therapist also checks for signs of irritation or complications, including increasing pain, swelling, numbness, or unusual changes in skin color. The therapist checks each cast for damage and proper fit to ensure it provides the intended support without becoming too tight or putting excessive pressure on your child’s skin.

Step 5: Cast removal and replacement

At a scheduled follow-up visit, your child’s therapist removes the cast using a specialized cast saw, then assesses your child’s range of motion to see how much progress they have made.

If further casting is needed, the therapist applies a new cast with the joint gently positioned a little closer to the desired range of motion. The therapist may repeat this process over several visits, with each cast building on the previous stage’s progress, until the treatment goal is reached.

Step 6: Follow-up recommendations

After the therapist removes the final cast, they may recommend stretching, strengthening, gait training, or an ankle-foot orthosis (AFO), a brace that supports the foot and ankle. These measures help maintain progress made during casting. Follow-up visits allow the therapist to monitor your child’s movement and adjust treatment as needed.

What can my child do while wearing the cast?

An ideal situation for someone in serial casting is to receive physical therapy along with it. This depends on each individual’s insurance. Our therapists can help develop a plan if you can get extra services. It is also encouraged to stay active by walking, stretching, and doing balance exercises. This helps maximize outcomes. 

Children are also encouraged to continue with activities as normal while wearing the casts, as the foot and lower leg are placed in an optimal position that encourages normal gait mechanics. When walking in casts, children can improve strength in weaker muscles and length in tighter muscles. 

During the casting process, we believe that a kid should continue to “be a kid.” In fact, parents have reported that their child is able to do more while wearing the casts. For example, parents have said they can’t believe that their child can stand still in the grocery store. One child’s mom thought he hated Halloween, but he just couldn’t walk comfortably for the duration of trick-or-treating. Now he goes on walks by himself outside. Another child couldn’t stand still on the risers for a school musical because they would tip over. 

How should parents care for a serial cast?

Parents and caregivers play an important role in supporting their child during serial casting. We change the casts weekly to gradually stretch tight muscles. Between visits, you can help keep your child comfortable, care for the cast, and let the therapist know promptly about any discomfort or concerns.

• Check the skin around the cast: Watch for redness, swelling, or soreness, and report any changes to your child’s therapist.
• Keep the cast dry: Protect it during bathing and follow your therapist’s instructions about water exposure.
• Encourage movement as directed: Walking, standing, and playing may be part of your child’s treatment plan. Follow the therapist’s guidance on safe activities.
• Keep the cast clean: Keep dirt, food, lotion, and other substances out of the cast, and do not insert objects to scratch underneath it.

After casting, follow any recommendations for physical therapy, home exercises, or orthotics to help your child maintain their progress and work toward their treatment goals.

What happens after serial casting?

Your child will wear daytime ankle-foot orthotics (AFOs) throughout the day and night splints to sleep in. The AFOs will hold the feet at a 90-degree ankle angle, and the night splints will hold them approximately 20-plus degrees beyond that. 

How long a child will be in their AFOs is dependent on: 

(1) Strength in the muscles that were once weak

(2) Maintaining the range achieved while casting. 

The hardest thing to change is the habit of walking on toes.  A family that is highly motivated to maintain strength and range and also break the habit will be out of the AFOs much quicker (roughly one year).

Watch for the “doctor walk” versus a casual walk back to the car, for example. A child may sometimes think hard about heel-toe-heel-toe walking when in front of the doctor, but if they walk to the car on their toes, it may be a sign they are not ready to be done. A child who is ready to come out should be able to walk and talk with their friends without thinking about heel-toe-heel-toe walking.

Plenty of parent training and homework should be done to help a child finish. A drill that can be done is to have the child lean their back and butt against the wall and do heel taps. This activates the quad and works the hip flexor. It will help them learn to keep their weight back. Also, children should do clockwise and counterclockwise leg movements and up-and-down leg movements, three times a day.

Parents must be careful to not remove the AFOs and night splints too early. If they are removed too early, they will not work on a child who has lost the range of motion. As a comparison, think of a person who wears a retainer after getting braces taken off. Not only will the range be lost, but the child may also revert back to walking on their toes.

If you think your child may need serial casting, talk to your doctor right away so it can be addressed and you have a better chance at quick outcomes. It may not always be something you grow out of. 

If you have more questions about serial casting, call (815) 469-1500.

Serial Casting vs. Other Treatments for Toe Walking

The right treatment for toe walking depends on your child’s age, the underlying cause, muscle tightness, and overall movement. Here’s how the treatment options compare:

What to Expect at Westside Children’s Therapy

If you’re wondering whether serial casting could help your child, our team at Westside Children’s Therapy is here to guide you. We start by observing how your child walks and moves, checking for muscle tightness, and measuring ankle range of motion. We’ll explain what we find, answer your questions, and create a plan around your child’s needs.

Casts are usually changed weekly. At each visit, we check your child’s progress and gently adjust the next cast’s position. Once casting is complete, we’ll guide you through exercises and any recommended daytime braces or nighttime splints to help your child maintain their progress.

Contact our team to learn more or schedule an evaluation.

Frequently Asked Question

What is serial casting used for?

Serial casting gradually improves a child’s joint flexibility and range of motion when tight muscles or contractures restrict movement. It is commonly used for conditions such as toe walking, cerebral palsy, muscle tightness, and ankle contractures. A series of casts gently stretches the affected area over time, supporting improved mobility and function. 

How are serial casts used for toe walking?

Serial casting gradually stretches tight calf muscles and improves ankle flexibility to rectify toe walking. The child’s ankle is gently positioned in a more neutral or dorsiflexed position, and a cast holds it there. The cast is replaced periodically, gradually increasing the stretch and helping encourage a heel-to-toe walking pattern. 

How often are casts changed?

Serial casts are generally changed weekly, although the schedule depends on your child’s progress, treatment goals, and response to the cast. At each appointment, we remove the cast, check the skin and ankle movement, and apply a new cast in a slightly adjusted position. 

Does serial casting hurt?

Serial casting doesn’t cause any significant pain. Children may experience mild pressure, tightness, or temporary discomfort as the muscles and tissues adjust to the stretch. But if they experience persistent pain, numbness, swelling, discoloration, or significant discomfort, report it promptly. 

How long does serial casting take?

The overall treatment period varies depending on the child’s flexibility, severity of tightness, and treatment goals. Serial casting may involve several cast changes over a few weeks. Each cast is typically worn for several days to two weeks, followed by reassessment and possible placement. 

How much does serial casting cost?

Cost depends on your insurance plan, the number of casting sessions, and any added services. Check our accepted insurance page, or call (815) 469-1500 and ask for the billing team. They can confirm your benefits and give you an estimate of weekly casting costs.

Can toe walking return after serial casting?

Yes, toe walking can return after serial casting, especially if the underlying factor contributing to the walking pattern isn’t corrected. Most healthcare providers prescribe follow-up treatments such as physical therapy, stretching, gait training, or orthotic support to help maintain the improvements. 

How do I know if serial casting may be appropriate for my child?

A pediatric physical therapist or another qualified healthcare professional can help determine whether serial casting is right for your child. During an evaluation, they assess how your child walks, how far their ankles can move, muscle tightness and tone, and overall development to recommend next steps.

Is serial casting safe for children with autism or sensory sensitivities?

Many children, including children with autism, can do serial casting, but a cast can feel unusual at first. Tell your physical therapist about any sensory concerns before starting so the team can plan ahead, such as talking through what to expect and building in breaks. If you’re not sure whether your child has an underlying concern, our autism screening is a good first step.

Can my child bathe or swim with a serial cast?

Keep the cast dry. Your therapist will give you bathing instructions, such as sponge baths or a cast cover, and you’ll skip swimming while the cast is on.

What if the cast gets wet or slips?

Call your care team right away. Don’t try to fix or remove it yourself. Contact your therapist if you notice swelling, numbness, discoloration, or pain that doesn’t go away.

Does my child need physical therapy while in casts?

Often, yes, when insurance allows. Physical therapy can support strength and walking while the cast works on flexibility. Your therapist can build a plan around your child and your coverage.

Where can I get serial casting?

Westside offers serial casting at select clinics. See locations that offer serial casting or contact our team.

Where to Go Next

• Curious what progress can look like from the first cast to the last? Check out more in Before and After Serial Casting: What Changes for Your Child.
• Wondering how casting is used for other conditions? Check out more in Serial Casting for Clubfoot: What Parents Should Know.
• Waiting to start and not sure what to do in the meantime? Check out more in What to Do While You’re on a Waitlist for Pediatric Therapy.

Sources

1. Cochrane Review: Treatments for toe walking in children not associated with a medical condition.
2. The Management of Toe Walking in Children with Autism Spectrum Disorder: “Cast and Go” (PubMed Central)