Orthoses for People With Autism Spectrum Disorder

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Contents

• Contents ………………………………………………………… 1
• Summary ………………………………………………………. 1 2.1 2025 Research Review …………………………………. 2
• Motor difficulties for people with Autism Spectrum Disorder ……… 2
• Effectiveness of foot orthoses ……………………………………. 6 4.1 What are foot orthoses? …………………………. 6 4.2 Effectiveness of treatment ………………………… 6 4.3 Foot orthoses for people with ASD ………….. 9
• References ……………………………………………………. 11

Summary

Research for this paper was originally completed in November 2021. An update was added in August 2025.

A lack of evidence exists regarding the effectiveness of foot orthoses for individuals diagnosed with autism spectrum disorder (ASD). However, there’s some indication suggesting foot orthoses can assist in

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treating and managing conditions associated with ASD. Foot orthoses may help reduce toe- walking. There is very little evidence that orthoses can assist with mobility in people diagnosed with Developmental Coordination Disorder (DCD), a condition associated with ASD. However, here is evidence that foot orthoses assist with the management of pain and associated function for a variety of other conditions such as flat feet, high arches, bunions, juvenile idopathic arthritis, rheumatoid arthritis and knee pain. Quality of studies vary.

2.1 2025 Research Review

The prevalence of motor impairments in individuals with ASD is confirmed in recent research. These impairments can affect gait and balance among other things. There is also evidencethat these impairments correlate with other symptoms of ASD such as impairments in socialskills and language and functional delays. It remains unclear whether the motor impairmentsexperienced by those with DCD have the same underlying sensorimotor mechanisms asthe motor impairments experience by those with ASD. Toe-walking also continues to be reportedas prevalent in individuals with ASD. However, studies on the functional impact of toe-walkingproduce contradictory results. In terms of ASD, the DSM-5-TR mentions odd gait, clumsiness,and other abnormal motor signs (e.g., walking on tiptoes).

Studies on the effectiveness of foot orthoses show improvements in gait-related parametersin individuals with various neuromuscular and musculoskeletal impairments. However, generalisability of these results is affected by small sample sizes, high risk of bias and lowstudy quality. Current studies on the effect of orthotics on individuals with ASD havelocusedon resolving toe-walking. These studies often combine orthotics with another intervention suchas serial casting or Botox injections. Results often show a decrease in toe-walking. Samplesizes are often small and blinding and randomisation are not used, making it difficultto generalise results.

3. Motor difficulties for people with Autism Spectrum

Disorder

2025 update: Research continues to confirm high rates of motor impairment in individualswith ASD, and motor impairments are a core feature of ASD according to research and peak andcommunity bodies such as Embrace Autism, the Autism Research Institute, and the NationalAutistic Society (UK). The prevalence of motor impairments in individuals with ASD has beenestimated to be between 35% and 95% (da Silva et al., 2025, p. 1; Miller et al., 2024, p. 2). in 2025, da Silva et al. published a scoping review of motor impairments in individualswith ASD looking at 19 studies of fair to good quality. Results showed that individuals withASD may have a range of motor impairments including a reduction in stride, a lower cadence, greater variation in stride width, and a change in the ankle joint during the pre-swing phase. Choet al. (2022) conducted an exploratory pilot study on 82 individuals with ASD whichshowed greater mediolateral deviation while walking, greater sway during normal, tandem,and single leg stance, a reduced walking speed and cadence, a greater arrhythmicityduring jumping jack.

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tasks and an impaired manual dexterity during finger tapping tasks compared to healthy controls. However, regarding motor impairments in individuals with ASD, the DSM-5-TR (2022) only mentions odd gait, clumsiness, and other abnormal motor signs (e.g., walking on tiptoes).

Studies also purport the high functional impactful of motor problems in individuals with ASD including its correlation with repetitive behaviour severity, language and functional delays, bhat: limited ability to engage in self-care behaviours, and current and future daily living skills (Bhat, 2023; Cho et al., 2022; Miller, 2024). A recent systematic review with two meta analyses also found that gross motor skills were moderately but significantly associated with social skills in children with ASD. The authors also explain that more research is needed to understand causality and directionality of the relationship (Wang et al., 2022). The 21 studies included in this meta-analysis had a mean total quality rating of 9.95 out of 13. A similar correlation was also found in a SPARK dataset analysis of 13,887 children by Bhat (2023). miller_et_al.: Miller et al. (2024) call for motor impairments to be recognised as a feature of autism and for uniform structure to the assessment and treatment of motor problems in autism. They question whether a cooccurring diagnosis of DCD is the best approach for individuals with ASD and DCD-like symptoms and call for more research to understand whether motor impairments in individuals with ASD and motor impairments in individuals with DCD stem from the same or different underlying sensorimotor mechanisms (Miller et al., 2024).

toe_walking: toë-walking continues to be reported as prevalent in individuals with ASD (Chapek & Kessler, 2025; Valagussa et al., 2024). Studies on its impact on quality of life have produced contradictory results. caserta_etal: Caserta et al. (2022) found that the 27 participants with idiopathic toe- waltking in their study exceeded Australian recommendations for physical activity but did not meet recommendations for screen time amounts or sleep times. On the other hand, morrow_etal: Morrow et al. (2024) found that the 157 children in their study showed significant reductions in physical, school and play, and emotional domain scores using the Oxford Ankle Foot Questionnaire for Children (OXAFQ_C) when compared to healthy controls.

asd_definition: Original 2021 paper: ASD is a neurodevelopmental disorder characterised by difficulties in social interaction and social communication, including restrictive, repetitive, and inflexible patterns of behaviour (American Psychiatric Association, 2013; World Health Organisation, 2019). dsm_notes: DMS 5 notes that people with ASD can often also experience motor deficits such as clumsiness and problems with gait (American Psychiatric Association, 2013). Motor deficits are included as ‘additional features supporting diagnosis,’ though there is a growing body of evidence supporting the idea that motor deficits are a core feature of ASD (American Psychiatric Association, 2013; Bhat, 2020; Ming et al., 2007; Zampella et al., 2021). bhat_study: in a study of 11,814 participants, Bhat et al. find 86.9% of children with ASD are at risk of motor impairments. zampella_etal:Zampella et al. report that up to 76% of children with ASD meet the diagnostic criteria for Developmental Coordination Disorder (DCD). DCD is a motor disordercharacterised by motor skills substantially below what is expected at a person’s age (Zampella)

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et al., 2021). People with ASD are also at greater risk of low muscle tone (hypotonia) and apraxia (Ming et al., 2007; Shetreat-Klein et al., 2014).

of particular interest is the prevalence of motor deficits that can affect gait. An earlier study on the prevalence of motor deficits in children with ASD finds 19% present with toe-walking, 9% a gross motor delay and 2% with reduced ankle mobility (see Table 1). A later study finds 68% of children with ASD have some form of gait abnormality (see Table 2) . Children with ASD are at higher risk of toe-walking (Caserta et al., 2019; Ming et al., 2007; sheatreat-Klein et al., 2014). Estimates of the prevalence of foot walking in people with ASD range from 9% (Leyden et al., 2019) to 20% (Barrow et al.; 2011; Ming et al., 2007; Valagussa et al., 2019). A 2015 review found considerable disagreement over the specifics of a pattern of gait in people with ASD concluding that deviations in gait are a common symptom of ASD (Kindregan et al., 2015), This heterogeneity is echoed by Dufek et al. (2017); who observe that the participants in their study displayed varied patterns of gait but generally showed an increase in gait abnormalities.

Table 1 The Prevalence Of Motor Deficits In Asd (Source: Ming et al, 2007)

Motor deficits	Age groups (years)	Hypotonia	Apraxia	Toe-Walking	Reduced ankle mobility	Gross motor delay
Presence	All	79 (51%)	53(34)%	30 (19%)	4 (2%) all children had history of toe walking	14 (9%)
	2–6	52 (63%)	34 (41%)	21 (25%)	2 (2%)	10 (12%) \
	7–18	27 (39%)	19 (28%)	9 (13%)	2 (3%)	4 (6%)\
	19+	27 (37%)	20 (27%)	12 (16%)	0 (0%)	6 (8%) \

Table 2 The Prevalence Of Motor Deficits In Asd (Source: Ming et al., 2007)

A review by Valagussa et al. (2019) found that the prevalence of gait abnormalities in people with ASD ranges from 11% to 35%

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Gait Abnormalities	Children with autism (n=38)	Peers (n=38)
Apratic	33	0
Posturing	25	11
Clumsy	20	0
Any abnormality (except toe-walking)	58	11
Toe-walking (observed on video only)	33	3
Any toe-walking (in office or on video)	45	3
Any gait abnormality (including any toe-walking)	68	13

Motor deficits in children can impact social interaction and communication (Zampella et al., 2021). However, the presence of motor deficit in individuals with ASD does not indicate that these individuals necessarily experience the deficit as an impairment or that they require a specific kind of support. As shown in Table 1, prevalence of motor deficits tends to reduce with age, although this is likely not the case for people diagnosed with DCd (Harris et al., 2015). Dietz and Khunsree argue that evidence for the harm of toe-walking is lacking and beyond social stigma; toe-walking may ultimately be benign (Dietz & Khunsree, 2012). On the contrary, Herrin and Geil urge that there are short and long term harms to toe-walking including:

• decreased walking velocity due to decreased stride length and cadence
• greater risks for falling
• greater effort than normal gait
• contracted Achilles tendon
• equinus position of the foot/ankle complex
• lumbar spine hyperlordosis
• deformities of bones and soft tissues in the feet
• abnormal adult gait (Herrin & Geil, 2016)

Leyden et al. (2019) note that some biomechanical and gait changes have been noted in people without toe-walking forms, though they temper this with observation that long term consequences of toe-walking are generally unknown. In one study, participants walking barefoot displayed toe-walking behaviour in 36% of steps (Michalitsis et al., 2019).

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find research to link frequency of toe-walking behaviour with real functional impact (i.e. research linking percentage of toe-walking footfalls with substantial mobility deficits). While it is clear from the evidence that people with ASD experience problems with gait and motor skills at a higher rate than people without ASD, hey do not receive treatment at a higher ate and continue to be under-diagnosed with motor impairments and DCD [Ming et al., 2007]. r### Effectiveness of Foot Orthoses

What are Foot Orthoses?

An orthosis or orthotic device is an “externally applied device used to compensate for impairments of the structure and function of the neuro-muscular and skeletal systems”[International Standards Organisation, 2020]. Common Lower Limb Orthoses include:

• Toe – designed to wedge in-between toes
• Insoles - able to slip inside shoes; available custom-made or prefabricated; can-be heel, 㑜 length-or full-length
• Sub malleolar– covers-the whole-foot but-stopping below-an ankle
• Supra malleolar– covers-the-whole-foot-and ankle
• Ankle-Foot– covers-all-or-part-of-the-foot,the-ankleand stops just-below-theknee. can-be articulatedor solid,linedorpaddedwithorthout-a sole
• Knee-covers-kne jointanda ndstops abovethe anklandbelowth ehipcanbe custom mouldedorprefabricated
• Knee-Ankle-Footcoversallorphartoftheadfootovertheankl andk neeands t op sjust b elow th eh ipjoint can bearticulatedatank leork n ee, fullyorpartlycustommould ed
• Hip-usuallycoveringlowerbackand hipj ointstopp ingbeforetk en , custom mouldedorprefabric ated

Knee-Hip-A nk l-e Footcover sa llorr part of the foot over an kel knee a d h i pbut shouldnotobstructmovemento fthespine[Black et al., 2010; Queensland Health,,

Effectiveness Of Treatment\r2025 Update: Caldeira Quaresma & McMonagle (2025) conducteda systematic review on efficacyoff lowerlimb orthoseson qualityolife,well-being,and participationinindividuals withstroke. Basedont hearticlesreviewed,the relationshipbetween low er limb ort hose sandquality olif ei snconistentwhiletherelationshipbetweentheuseoforthosesand

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A systematic review conducted under the National Disability Insurance Act, psychological well-being and participation is mostly positive. However, the level of evidence was low to acceptable for most studies with only two receiving a rating of high. The authors present information based on other studies that lower limb orthoses improve mobility, ambulation, gain, energy costs, balance and walking speed in people with stroke (Caldeira Quaresma & McMonagle, 2025, p. 388). Faccioli et al. (2025) conducted a systematic review and meta-analysis on the role of ankle-foot orthoses in improving gait in children and adolescents with neuromotor disability. The meta-analysis component, which focused only on 5 randomised controlled trials of individuals with cerebral palsy, showed ankle-foot orthoses are effective in increasing stride length, ankle dorsiflexion at initial contact and peak ankle dorsiflexion in stance while reducing cadence and the energy cost of walking. In terms of risk of bias, these studies showed only ‘some concerns’ according to Faccioli et al. Another systematic review (Pollen et al., 2025) explored the efficacy of 3D-printed ankle-foot orthoses on gait in patients with neuromuscular and/or musculoskeletal ankle impairments. Ten studies of fair to good quality were reviewed and included gait parameter outcome measures such as kinematics, kinetics, plantar pressure/force, and spatiotemporal data. Results showed a myriad of changes including increased gait velocity and cadence (see pp. 296–298 for more details). Bollepalli et al.’s 2025 systematic review of orthoses for in-toeing and out-toeing found that foot orthotics may be appropriate for mild gait abnormality management. The majority of studies included in this review were at low risk of bias while the remaining studies were at moderate risk of bias.

Various recent studies have shown that different types of orthoses may produce positive results for some populations. These include those with unilateral drop foot associated with multiple sclerosis (Pourhoseingholi & Tafti, 2025), plantar flexor weakness post-stroke (Skigen et al., 2024), patellofemoral knee pain (Simon et al., 2024) and hip osteoarthritis (King et al., 2024). However, these studies typically have small participant numbers (<30). A redacted: s22(1)(a)(ii) - irrelevant material also persist such as the different styles, design and manufacture methods of various orthoses and the variety and combination of materials used in orthoses under study. These variations make it difficult to compare studies, and difficult for results to be generalisable.

The original 2021 paper: Foot orthoses are a commonly prescribed treatment and management technique for a variety of lower body pain and functional/mobility issues. Orthoses, prescription footwear and physical therapy are often called ‘conservative’ treatments to contrast these with surgical interventions (Martikyan et al., 2018). A 2008 Cochrane review of eleven randomised control trials found evidence that custom made insoles can reduce the pain associated with high arches (pes cavus), juvenile idiopathic arthritis, rheumatoid arthritis and bunions (hallux valgus). The review found mixed evidence that custom insoles reduce pain of plantar fasciitis (Hawke et al., 2008). Results were mixed for different conditions. Use of custom insoles for at least three months decreases pain associated with high arches, improves function and quality of life (Burns et al.; Hawke et al., 2008). Children experiencing juvenile idiopathic arthritis can benefit from

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custom insoles or prefabricated neoprene insoles. Both interventions were more effective than supportive footwear at reducing pain and disability and improving function. After three months, pain reduction was seen among patients experiencing rear-foot pain due to rheumatoid arthritis but no change after years compared against placebo treatment between treatments did not show statistically significant improvements either way. Custom-made inserts do little better regarding metatarsophalangeal joint discomfort related specifically to RA as opposed to standard shoes or non-customized braces; however they may help alleviate bunions’ associated agony somewhat while surgery might yield superior results though without any discernible functional improvement noted thus far according to Hawke et al.,2008). A Cochrane review conducted on foot orthotics usage aimed towards knee ache concluded some short-term relief within six weeks yet also reported increased occurrences such as blisters and rubbing amongst treated subjects versus those receiving physiotherapy alone; similarly there existed negligible differences when comparing outcomes for both groups with regard solely toward alleviation levels achieved respectively (Hossain et.al, 2011) another study focusing upon children suffering from Pes Planus found evidence suggesting custom-designed devices could aid significantly in mitigating symptoms albeit limited by small sample sizes risk of bias difficulties encountered during data analysis Rome et all , two decades ago Footwear solutions including full-sole designs or ankle-brace types are frequently employed therapeutically targeting toe-walking issues especially if individuals possess adequate range-of-motion capabilities alongside willingness undergoing gait retraining Caserta et al, having observed that although initial use effectively curtails the condition’s progression it fails entirely once treatment ceases Herrin & Geil report similar findings regarding their randomized controlled trial which was prematurely halted after just three months instead planned duration leading them conclude sequential application strategy wherein less restrictive options like simple inserts precede more rigid alternatives might prove beneficial. The challenge lies even amidst high-quality research studies where conclusions about overall efficacy remain elusive due to variations among different styles materials used manufacturing techniques etc.,Queensland Orthoses ASD Page8of15

Foot Orthoses for People With ASD

A systematic review by Luginsland et al. (2024) focused on biomechanical gait interventions for individuals with ASD including orthopaedic interventions such as serial casting and/or ankle/foot orthoses. Only three studies in the review focused on orthoses. Participants with toe-walking who underwent both serial casting and foot orthoses showed improved overall kinematic and spatiotemporal parameters during gait. More specifically, participants who underwent serial casting followed by foot orthoses in two studies showed an increase in ankle dorsiflexion, while participants in another study who used just foot orthoses showed an increase in peak force of the hallux and first metatarsal heat and a reduction of plantar pressures. In terms of study quality and bias, none of the studies used randomisation or blinding and all showed a low risk of reporting bias. Wilder et al. (2022) evaluated shoe inserts in two children with ASD and toe-walking. Toe-walking was heavily reduced in one child via the use of shoe inserts. The second child also showed reduced toe-walking with the shoe inserts, but his toe-walking was further reduced by the hand-on-shoulder technique which involved one of the researchers placing gentle pressure on the participant’s shoulder if the participant began toe-walking. During follow-up probes, the levels of toe-walking in both participants did increase slightly compared to levels during the active intervention (insoles) phase but did not return to initial levels. It is worth noting that one of the participants had previously been treated with ankle orthotics without success (redacted: p. 756). A 2022 study by Manfredi et al. discusses treatment of toe-walking in individuals with ASD using the “Cast and Go” protocol. This protocol involves a botulinum toxin injection, serial casting and orthoses associated with physiotherapy to achieve ankle neutral position. 22 children underwent treatment via this protocol with the outcome being the correction of the ankle dorsiflexion angle. Initially, the injection is performed and then casting is applied 4–7 days thereafter. Allied health professionals are then engaged to assist with plaster walking.

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Orthoses are used only nightly after plaster removal. Multiple consecutive casts could be employed for a maximum of 35–40 days. The whole protocol could be repeated after one year if the ankle dorsiflexion angle remained at more than 90 degrees, but the protocol could not be repeated more than 3 times (Manfredi et al., 2022, p. 4). In this study neutral angle position was achieved in all participants, with the maximum length of treatment being 50 months and the average length 13 months.

in the 2023 response of the Australian Podiatry Association (APodA) to the draft version of the updated National Guideline for the Assessment and Diagnosis of Autism in Australia, APoDA state that by prescribing appropriate orthotic devices they can address motor challenges improve motor function and enhance the overall quality of life for individuals with ASD. APoDA also states that through the utilisation of devices such as shoe inserts and ankle-foot orthoses podiatrists can help individuals with ASD manage sensory sensitivities and promote better mobility and balance. However no recommendations regarding podiatry or orthoses are included in the National Guideline for the Assessment and Diagnosis of Autism (2023).

original 2021 paper: We did not find any literature specifically focussing on prescription of foot orthoses for people with ASD. Valagussa et al. (2018) mention only 2 studies that look at treatment of toe–walking in people with ASD. We found 3 papers that mention foot orthoses as a treatment option for people with ASD and none of them look at this option in depth (Ming et al., 2007; Valagussa et al., 2019; Martikyan et al., 2018).

A summary of evidence based treatments for ASD endorsed by the European Society of Child and Adolescent Psychiatry only briefly mentions motor deficits and notes only occupational therapy as a possible treatment (Fuentes et al., 2021). Martikyan, Kaur, and Patel point out consideration of the particularities of ASD which might complicate treatment of toe walking are absent from the current literature (Martikyan et al., 2018). For example Leyden Frung and Frick conclude:

Current [idiopathic toe-walking] treatment guidelines do not include specific recommendations for patients with comorbid conditions like ASD and nonoperative treatments may be more challenging in patients with ASD if the patient has difficulty complying with instructions sensitivity to tactile foot sensations/manipulation or is disturbed by the noise of cast saws. Medical treatment decisions should consider family preference severity of the patient’s condition as well as any comorbid conditions (Leyden et al., 2019).

as shown in 3 Motor difficulties for people with Autism Spectrum Disorder people with ASD are at a much higher risk of DCD (Zampella et al., 2021). Podiatrists in Australia tend to think foot orthoses will be a viable treatment option for people with DCD however according to one analysis podiatrists more familiar with DCD are less likely to prescribe orthoses (Smith et al., 2019). There is very little evidence to suggest foot orthoses will have positive outcomes for people with DCD.

References

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  • Diagnostic and statistical manual of mental disorders : DSM-5 TR .
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• American Psychiatric Association Diagnostic And Statistical Manual Of Mental Disorders : Dsm-5 (R) . Edition: Fifth edition., Publisher: American Psychiatric Association Publishing , PDFDrive.com - Australian Podiatry Association, 2023 Draft version National Guideline For The Assessment & Diagnosis Autism In Australia Response By APodA , [podiatry org au/documents/item/2953](http://www.podiatryorgau/ documentsitem2953) -Barrow W J Jaworski M Accardo P J Persistent Toe Walking in autism Journal Child Neurology Vol(26), No.(5), pp[619–621]([DOI link](https://doi.org/10.1177% /0883073810385344)) -Bhat A Multidimensional motor performance children with autism mostly remains stable age predicts social communication delay language functional repetitive behavior severity after accounting intellectual disability or cognitive delay SPARK dataset analysis Aut Res vol(16), no.[pp{208} – {229}] (link to DOI)
• Bhat AN Is Motor Impairment ASD Distinct From Developmental Coordination Disorder Report from the SPARK Study Physical Therapy Vol (100) No .(4) pp 633- -644 (Link To DOi) Black JA Matheson I Orthoses In Frownen ODonnell Gordon Burrows Lorimer Eds Neale s Disorders Of The Foot Clinical Companion Elsevier [Google Books Link](http://www.google.com.au/books/editio nNealesDisordersOfTheFootClinicalCv4zWDf1fs o4c?hl=en&gbpv=1dq=%E2%80 %99sdisordersofthefootclinical+companionpgPA37printsecfrontcover) -Bollepalli H White CJ K Kodra JD Liu X C An Evaluation of orthotics on in-toeing out toeing gait Healthcare Basel Vol.5 No.(13) P[531]([DOI link ](https:// doiorghealthcare13050531 )) Burns J Landorf KB Ryan MM Crosbie J &Ouvrier RA Interventions for prevention and treatment pes cavus Cochrane Database Systematic Reviews vol(12), CD006154 ([link to DOI](https://doi org/ 10.%u00A014651858CD006154pub2 ) Caldeira Quaresma D McMonagle C Efficacy lower limb Orthoses quality life well-being participation following stroke systematic review Prosthetics And Orthotics International, [Vol (49)]No.[pp{388} – {399}] , ([Link To DOi](http://www.ndis.gov.au/ doi.org/%10 .1097PXR%0000000000000389))