14 month old toe-walker

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Premature (26 weeks)

1 of 2 identical twins (female)

Unlike her sister with 'normal' gait, patient is a bilateral toe walker (tip-toes).




Plan (a). Gastroachilles stretching which is not tolerated well by infant. 3 weeks...gait unchanged.


What should plan (b) be?


i. heel lift/raise implementation, then gradually weaning to encourage heel contact?

ii. AFO via orthotist to force plantargrade during weightbearing for 2-4 weeks?

iii. Night splint - gastroc/achilles stretching progressing from mild...then to moderate etc.

iv. combination of...

v. Other options



Any other differential diagnoses that I should be aware of?



Thanks in advance...


Ron
Physiotherapist (Masters) & Podiatrist

 

Due to the prematurity and inability to stretch, your first and foremost referral should be a paed/neurology referral to rule out CP.

Micro-prems have a high incidence of CP which should be initially ruled out prior to treatment. What is the reflexes like? The tone? Is there a catch on rapid dorsiflexion? While the walking is definitely within the normal age bracket, to be toe walking with gastrocsoleus tightness at this age, there is generally something neurological happening. Most early idiopathic toe walkers do not have gastroc soleus tightness this early and do not spend a heap of time on the toes, that increases as they get older.

The other DDx with micro-prem's is Global Developmental Delay and/or low tone. The gait pattern is actually far more energy efficient. There is also a link with the microprem and sensory issues, though there is no definate link with sensory issues and toe walking at the moment. There is however a link with prem's and sensory issues. There is a stack of things it could be however CP is your first concern.

I'd delay all treatment until you have a diagnosis first as the diagnosis will lead you to the most appropriate treatment path.

 

Bug wrote "..CP which should be initially ruled out prior to treatment.."

Not saying that the possibility of CP should not be looked at.

But with any child that toe walks would a diagnoses of CP change your treatment as to if the child did not have CP?

 

I agree with Cylie that one must keep the possibility of cerebral palsy (CP) high on the differential diagnosis list. However, at the age of 14 months, toe walking is not that uncommon and typically is self limiting, with most of these toe walkers walking more normally by the age of 3-4 years. I was taught by Dr. Ron Valmassy to try just putting these children into shoes with a stiff, inflexible sole that limits the child from dorsiflexing their metatarsophalangeal joints for 2-3 months as a start. The stiff soled shoe would encourage walking more plantigrade with the heel on the ground. These shoes can be worn while the patient is being evaluated for possible CP.

Hope this helps.

 

I'd say these prem kids are doing well walking at 14 mths, and agree that lots of tots seem to toe walk on and off at first. knowing how 'encouraging' us parents can be had they had a 'helping hand' in walking eg bouncers, walkers, etc? As Cylie points out are there any other symptoms? Its very easy for parents to become paranoid about the development of their children and are always comparing with others (whether we admit it or not!!) and having an identical twin I'm sure these 2 will be compared for the rest of their lives!!

Just thinking outside the square a bit!!

 

Thanks Kevin, I would agree with a stiff soled shoe in the early days as a perfect form of treatment in the younger child. It is totally normal for a toddler up to the age of 3 to toe walk. If they can never get their heel to the ground though it is an issue. One of the hardest things though to differentiate though with a young child is an absence of heel strike when the child is still in a flat foot gait pattern. Very mild CP can still have a low/absent heel strike but still look like they are getting down onto their heels.

David, yes, it could change your treatment dramatically. In this case, you would want to ensure they are referred for diagnosis, proper assessment and if there is hand/upper body involvement. Treatment for the toe walking then may be casting or botox, splinting etc. Stretching just doesn't work with CP. Identifying the major cause for the lack of heel strike is also a priority, what may look like Gastroc may be the hamstrings or hip flexors kicking in when they aren't meant to. BUT, if it isn't CP, then the above treatments are way too aggressive for toe walking in a child this age.

I would also argue strongly that a stand alone podiatrist is not the ideal person to treat toe walking from CP. Any child with CP needs someone with the right training in neuromuscular rehab and be up to date on the current treatment methods. Any child with CP needs to be linked in with a service that can provide all forms of allied health to ensure they are all talking and continuity of service between the Medical and Allied Health teams.

 

Hi all,
I love to think outside the square. Idiopathic toewalking is a topic close to the heart that I enjoy attempting to put a cause to it. And I completely agree this prem bub is doing really well to be walking by 14 months, when you consider they were born up to 12 + weeks under developed compared to their peers.

Bilateral toe walking can be initial symptoms of many pathologies.
- Dushenes Muscular Dystrophy
- Autism
- Cerebal Palsy
- Achilles Tendon contracture
- Mild Talipes
- spinal cord abonormality
- hamstring contracture
-i diopathic toe walking

Diagnosis in all of the above cognitions requires a multidiscplinary approach not to mention, a thorough birth history, medical history, neuromuscular assessment and developmental history. How is the patients hearing? Something as broad as hearing may provide useful information.

Is she the 1st or the 2nd twin, what was her delivery of neonatal care like. Did they use the veins in her feet to deliver any IV fluids or medications? Could IV delivery through the feet leave a child sensitive?

Thanks Alicia:bash:

 

Great list Alicia!!! Just to add to that comprehensive list:

Global Developmental Delay
Not just autism but Autistic spectrum disorders
Angelman's Syndrome
Transient focal Dystonia
Developmental Coordination Disorder AKA the good old Clumsy Child Syndrome which is now defunct terminology.

Listing these is not to show off how much I love treating toe walking and how excited I get when others share this joy, but to highlight just how many things can cause toe walking. The need to establish a cause or at least to confidently rule out the presenting key indicators of those diseases is imperative to how this child is treated. Mainly because there is a difference in the treatment and success of the treatment and the long term impact of it/the cause on the child.

How much responsibility do we hold for a child's health if we are just treating the feet and suspect there other "stuff going on?" If anything, the long list highlights the fact, you either need to really, really know what you are doing or have access to people that do, prior to confidently commencing treatment other than a shoe and maybe a little triplanar wedge.

This is fascinating and a great topic to hear those that work in neonatal care chat about, thanks for thinking of it, Alicia! I understand you are starting to get more and more referals about this?
The ideal treatment then being exactly what Kevin already suggested?

 

THanks Cylie for your great responses. Have you considered presenting some of these paeds cases at the National Conference. I would love to see some of your cases and your treatment methods and your role as part of the paeds team.

 

Thanks Linda,

National isn't really the right forum unfortunately at the moment. I have a poster going in about toe walking and it's associated conditions though. There will be 2 great presentations on idiopathic toe walking by a physio and podiatrist in our hospital that have been researching idiopathic toe walking and have some excellent findings on how to treat the equinus component that can be associated. I'm more like Alicia though, I am hankering to find a cause for idiopathic toe walking, only then will we be more effective in our treatment methods of the habitual nature of the gait style rather than just treating the equinus component.

BUT keep your eye's peeled for a Paed's conference later in the year. Date is coming out very soon, you can hassle the poster above me for more information. I have no doubt she will pop it in the conference section here

 

I think the interesting thing here is that they are monozyotic twins but only one is toe walking!

As stated previously here, not uncommon and will most likely "grow" out of it.

Again, the very interesting thing is WHY do kids habitually toe walk at early stages. Here you have a great opportunity to perhaps give insight to why.

Apparently you can discount anything inherited and concentrate on environmental, delivery trauma, positional, learned, diet, on and on.........

Steve

 

Exactly.



Ron
Physiotherapist (Masters) & Podiatrist

 

Yes, but Ron and Steve, that rules out the most dramatic and least likely options anyways? The resultant list is still very long indeed. You really only factor out MD and CMT. The jury is still out on autism etc and gene's though the likelihood is higher but not definite.

Steve, wondering what your thoughts are on diet? I see you mentioned that in your post or was that just an entry into the long list of things it may be attributed too?

Ron, I'm sure I have seen your name around Melbourne. If you need a service to refer this patient to for assessment just give a pm and will give you the details.

 

Hi BUG!
Diet?
Well, you are what you eat!
One can blame diet for just about everything....google "diet toe walking" and you may be surprised at what you come up with.

Steve

 

Thanks Steve. As I suspected: "I tried this for my toe walking child.....oh, he also has autism."

 

Has anyone considered the far more simpler option rather than always the most complicated. This is a set of identical twins, and the "toe-walker" is the second twin (I'm assuming), and is therfore the smaller of the two (again an assumption). Is it purely being shorter, she is trying to gain as much height as her sibling to compete (as all twins do), and to achieve this she has to "toe walk".

Just purely a suggestion, in the midst of an extremely comprehensive list of DDx.

Cheers, :drinks

James

 

Interesting theory James.




I went with KK's suggestion and went for the thin-shank internal shoe stiffener of 2mm poly. It did make a mild-to-moderate difference on initial re-evaluation of gait.


2 weeks later, despite sporadic wearing, gait normalised to the extent that the toe walking was not obvious.




Ron
Physiotherapist (Masters) & Podiatrist

 

Glad to hear you had a good result in the end.

Never under-estimate the power of sibling rivalry! I have younger sisters who are identical twins, so have had first-hand experience of this.

Cheers, :drinks

James