Serial Casting for Ankle Contractures in Pediatric Cerebral Palsy: A Practical Guide

Hey colleague, let's talk about serial casting for our kids with CP who are fighting ankle contractures. We all see it – that persistent toe-walking that just gets tighter over time. A big systematic review and meta-analysis from 2020 by Milne and colleagues really solidified what many of us have seen in practice: serial casting works. This isn't just about stretching; it's a powerful tool to improve ankle dorsiflexion passive range of motion (PROM) and even reduce hypertonicity in the short term. The study, a review of 25 articles, found strong evidence that a series of casts can significantly increase that crucial ankle range. The typical protocol involves weekly cast changes for about 3-6 weeks. Each week, you remove the cast, gently stretch the ankle into a bit more dorsiflexion, and re-cast it in that new position. The key is that prolonged, gentle stretch. The evidence shows this leads to better functional gait in the mid-term. Think better heel strike and improved clearance during swing phase. What about adding Botox (BTX-A)? The review found that combining casting with BTX-A injections does give a slight, statistically significant boost to PROM improvement—about 3 degrees more than casting alone. However, the authors rightly question the clinical significance of just three degrees. Plus, they noted more adverse effects when BTX-A was in the mix, likely due to muscle weakening. So, for many patients, casting alone is a highly effective and less invasive first-line approach. The takeaway is that we have solid, high-quality evidence to support using serial casting to get these kids' feet flat on the ground and improve their walking.