Skip to main content

Ellen Thompson

Powys Teaching Health Board

This Bevan Exemplar project provided treatment locally to improve the calf muscle strength and walking ability of young people who walk on their toes and have tight calf muscles.


Serial casting is a common treatment for children and young people who walk on their toes and have tight calf muscles. The main patient groups are idiopathic toe walkers (where there is no underlying medical reason), and children and young people with cerebral palsy. The main aims of serial casting are to improve calf muscle length, improve walking pattern and efficiency and to reduce pain. There is a strong evidence base showing serial casting is an effective treatment.

Serial casting involves the application of a series of casts, progressively increasing the amount of dorsiflexion (foot upwards movement) to stretch the calf muscles with each cast. Single or bilateral casts may be applied and casts are left in place for a period of several days to 1 week. Clients are able to walk around in their casts, which helps to provide an active stretch.


Historically, in the large and rural county of Powys, serial casting has been provided by out-of-county hospitals, making access difficult and involving children and their families travelling long distances. This project aimed to provide a local serial casting service, ensuring good access close to home by a local team already known to the young person and their family.


The main challenge the project lead and team have faced is time constraints. It has been difficult to fit in doing the project around their regular busy caseloads, often resulting in working late to get things done. In recent months the project lead has had some protected time which has been really helpful and allowed her to audit and evaluate the project outcomes. The support and enthusiasm from clients and their families has motivated the team to keep going: “they really wanted this service and have been really positive about the benefits”. The project lead has been inspired by fantastic support from some of her colleagues.


21 children, aged from 18 months to 15 years of age, have now received treatment. The team has provided 124 contacts, 48 episodes of care and applied 125 casts.

  • The total mileage saving for children and their families (by providing local treatment compared to out of county providers) is 5705 miles, an average of 272 miles per child.
  • The total time saved for children and their families is 213 hours, an average of 1.6 school days per child.
  • Cost savings were substantial based on NHS England payment-by-results tariffs, the local service has provided a cost saving of £26,552 over 1 year and 9 months.

Next steps:

To date, the service has been piloted mainly in north Powys with 2 Physiotherapists and 1 technician specialising in putting the casts on. The team now aims to widen out the service to the whole of Powys and to train other members of the team to specialise in applying the casts. They also aim to further develop expertise in providing removable casts and serial resting splints, in order to bring the advantages of serial casting to a wider range of patients.

“Bevan Commission has provided a framework, support and inspiration to enable me to complete this project. Brilliant training events have helped me understand how to engage my team in a process of change and development.”

Ellen Thompson, Community Paediatric Physiotherapist

“To have the casting provided locally benefits us as a family, time and flexibility of location.”

“My child feels more relaxed in the environment he is familiar with. It also allows me not to have to book a whole day from work.”

“Very helpful due to not having a car and depending on local transport.”

Patient families