Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Everything that you are ever going to want to know about running shoes: Running Shoes Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
  2. Have you considered the Critical Thinking and Skeptical Boot Camp, for taking it to the next level? See here for more.
    Dismiss Notice
  3. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Habitual toe walker

Discussion in 'Pediatrics' started by LCG, Sep 27, 2006.

  1. LCG

    LCG Active Member


    Members do not see these Ads. Sign Up.
    Hi all,
    I thought I would share a case with you all in the hope of some further input. I have a 9 year old very active female who presented to the clinic with parental concerns regarding toe walking. Her parents had noticed this habit start approx 12 months ago and feel that she had progressively increased the amount of time spent walking on her toes in the last 3 months. Previous consultations with other health professionals had resulted in stretching exercises and heel lifts.
    Examination revealed a significant soft tissue equinus of both feet. Ankle joint dorsiflexion ROM testing revealed a signifcantly reduced value of 30 degrees
    (norm 42-52). The patient had reported difficulty with prolonged activity with pain in the gastroc/soleus muscle complex in the last 3 months with prolonged physical activity ending in tears. There appeared to be no bony blockage in ankle joint range of motion and there was an absence of neurological complications.
    My initial consultation resulted in modified stretching exercises , footwear modifications (heel lift and rigid forefoot) and activity modification. A review four weeks later revealed a significant improvement in ankle joint Dorsiflexion ROM (38) but the pain post activity had actually worsened. I am a bit lost as to the pathomechanics of the pain actually getting worse with improved ankle joint ROM??
    My next step was going to be a period of night splinting in a strassbourg sock, but am sceptical as to wether this will reduce her discomfort. Any thoughts on the managment of this child. When should I consider a surgical opinion considering the absence of neurological symptoms and improvement in ROM with stretching???
     
  2. jb

    jb Active Member

    Just out of interest, does the subject have any older siblings?
     
  3. LCG

    LCG Active Member

    yeah an older sister who toe walked for about 2 months but grew out of it and is asymptomatic
     
  4. deco

    deco Active Member

    Hi,

    Possibly use a nightsplint (custom moulded AFO) combined with a full length knee gaiter. The gaiter will maintain the knee in full extension thus ensuring best possible stretch on gastrocs. I would explore this option before looking at more invasive options

    Best wishes

    Declan
     
  5. Children going through growth spurts often lose muscle flexibility from my observations.
    Especially in the gastrocs and hamstrings, as their skeletal development grows upwards, the muscle is slow to lengthen to keep up - the long muscles crossing articular junctions especially. The sporty kids are worse as their activity encourages tone and strength in the muscle - at the expense of length and flexibililty. They NEVER stretch to compensate! Lots of stretching is needed. Passive with parental help, self directed from the child and night splinting may all be useful - especially after any activity, and again an hour or so after activity end. Sure the pain is within the muscle body, and not the calcaneal epiphiseal plate?
    Low dye strapping is very useful. Better make sure the 'Sport Billy' isn't partaking in trampolining!
     
  6. carol

    carol Active Member

    As an ex 'sufferer' myself who was dragged to many specialists, had to endure calipers, hard orthotics and the hideous shoes that went with them, not to mention scare stories of surgery, I simply grew out of it...when I went to secondary school and was allowed to wear heels... I'm 48 now and have no lasting problems.
    My advice..ignore it...Please! Once Mummy has made a fuss the attention is wonderfull! I know!
     
  7. shanam

    shanam Welcome New Poster

    Now. 9 y/o, no neuropathology, no boney blocking - percutaneous ach len... It sounds good to be. Has worked very well for me. I like to cast for a little longer than the lit suggests, 6-9 weeks.
     
  8. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    Maybe we need to clarify some terminology - a "habitual" toe walker by definition is a toe walker that has no pathology... ie they do it out of habit. Its a common cause of toe walking and needs NO intervention --> they always come right (unless they have some sort of tactile defensive pathology)

    The patient on the first post has an equinus --> not a habitual toe walker.
     
  9. carol

    carol Active Member

    Dear Craig,
    oh how I agree, what I was trying to say, having been on both sides of the fence, is once it is established as 'habitual' then leave well alone. Too often we are cajoled by pushy parents (my Mum bless her) into intervening when none necessary, the attention even prolonging the issue.
    In the two I have treated one was 'habitual' (wannabe dancer)& one was undignosed cerebal palsy (immigrant child) Both sucessfully treated.
     
  10. LCG

    LCG Active Member

    I am not sure I understand Craig. Can't the habit of toe walking lead to the equinus or are you saying the equinus has led her to toe walk? bit like the chicken or the egg scenario.
    There seems to be alot of conjecture with regards to treatment here.
    To bring everyone up to speed I have continued to treat the equinus ie heel raises and stretches and have also trialled low dye taping with sport. This is still not getting any results in response to pain management. The child is still complaing of medial belly mid portion gastroc pain. I Am trying to source a childs size strassbourg sock as mum has reservations about the child complying with a righid night splint such as an aquaplast splint.
     
  11. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Outcome of patients after Achilles tendon lengthening for treatment of idiopathic toe walking.
    J Pediatr Orthop. 2006 May-Jun;26(3):336-40
    Hemo Y, Macdessi SJ, Pierce RA, Aiona MD, Sussman MD
     
  12. SunnyC

    SunnyC Member

    Hi,

    I am a student of Podiatry from AUT University in NZ. I was curious to whether your 9 year old patient is showing a positive helbing's sign (aka medial bowing of the achillis) and have you thought about posting a medial wedge to 'straighten' the tendon. I have also read and heard that manipulation has helped improve ROM at the ankle. (Manipulation Method for the Treatment of Ankle Equinus by Menz and Dananberg JAPMA 2001; 91(2) 105-106).
     
  13. LCG

    LCG Active Member

    Rear foot frontal plane mechanics are normal. I have tried manipulating the head of the fibula after ankle joint dorsiflexion testing and have re-tested but have found little difference in the results. I think if anything the joint "feels" more mobile ie quality of motion, in passive talo crural examination but have found fibula manipulation to have no effect in actually improving the range of motion
     
  14. Dikoson

    Dikoson Active Member

    I am a clinical specialist orthotist in the UK. I have seen a number of patients with very similar case history.

    Anecdotally i have found that heel lifts, rigid soled footwear and nightsplints have little effect on these patients.

    Have you checked for proximal weakness? Weak hip extensors/tight hip flexors is a common finding in these patients as is poor core stability in the trunk. Toe walking significantly alters the effect of the ground reaction force (GRF) effect on required muscle activity in hip extensors. The most common example of this is duchenne muscular dystrophy and its known associated conditions. By toe walking and increasing lumbar lordosis the GRF is translated behind the hip generating hip extension moments therefore assisting in hip extension and reducing the muscular effort required by the patient. If the patient continues to go onto their toes in the presence of a rigid extension to the sole plate of the shoe it is likely there is an element of hip extensor weakness/hip flexor tightness.

    Hopefully a detailed physiotherapy exam and programme can resolve this unless their is an undiagnosed neurological condition.

    If this is not the case then their are orthotic devices that can assist. Static positioning for these patients in order to get a stretch is often uneventful and poorly tolerated. There are increasing dynamic systems that can provide an extension torque across the knee, ankle and hip. The most common systems can be seen at www.ultraflexsystems.com (from memory).


    I am very aggressive in managing this condition. Rigid AFO's (ankle foot orthoses) custom made with an adjustable plantarflexion limiting hinge and free dorsiflexion is my preferred option. Heel raises are added externally and reviewed weekly in conjuction with intense physio and personal physio programme to strengthen proximal extensors and stretch hip flexors.

    Even when the patient is able to walk with a heel toe gait, the hinged AFO's with plantarflexion limitation are maintained to prevent recurrence of toe walking through growth.

    I hope this is useful

    Best wishes

    Simon
     
  15. deco

    deco Active Member

    Hi Simon,

    why articulating AFO's?

    ta

    Declan
     
  16. Dikoson

    Dikoson Active Member


    Declan,

    Articulating AFO's allow the dorsiflexors to remain active while blocking various ranges of plantarflexion. Static (rigid) afo's are likely to cause disuse atrophy particularly to the dorsiflexors. They also allow the range of motion of the ankle joint to be controlled and easilt altered. Also more cost effective. Does require regular modification to heel raise but tolerance is better.

    Simon
     
  17. deco

    deco Active Member

    Hi Simon,

    would your criteria remain similar with gastroc tightness

    ta

    Declan
     
  18. Dikoson

    Dikoson Active Member


    Not necessarily, i do a lot of serial casting but remove an anterior wedge from the cast at the anterior ankle so the cast slowly deforms allowing increased ankle dorsiflexion. Always a long leg cast though otherwise gastroc tightness may caused increased knee flexion

    Simon
     
  19. deco

    deco Active Member

    good concept re long leg cast and anterior wedge with deformation. Getting back to articulating AFO's I feel that they are often incorrectly used in situations where there may be adequate ROM at TCJ (full knee extension) but proximal knee/hip muscle weakness results in crouch.

    Do we not get best stretch on gastrocs in 3rd rocker in gait when extension moment is greatest?

    Sorry, drifting off topic

    Dec
     
  20. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Classification of idiopathic toe walking based on gait analysis: Development and application of the ITW severity classification.
    Gait Posture. 2006 Dec 8;
    Alvarez C, De Vera M, Beauchamp R, Ward V, Black A
     
  21. Paul B

    Paul B Active Member

    Dito,

    Byond 3yoa raises concerns.

    Dig deep,

    PB
     
  22. Fitz

    Fitz Welcome New Poster

    Have you thought of chirporactic to ensure muscles are being innervated properly?
     
  23. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Muscle compensatory mechanisms during able-bodied toe walking.
    Gait Posture. 2007 Jul 9; [Epub ahead of print]
    Sasaki K, Neptune RR, Burnfield JM, Mulroy SJ.
     
  24. Footsies

    Footsies Active Member

    What are all the assessments we should be doing when a toe walker somes into the clinic?
     
  25. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    1. Gait (eg use of 3 rockers)
    2. Neuro assessment (eg cerebral palsy)
    3. Behavioural history (eg autism)
    4. Bioeval (eg limited RoM)
     
  26. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Idiopathic toe walking: a kinematic and kinetic profile.
    Westberry DE, Davids JR, Davis RB, de Morais Filho MC.
    J Pediatr Orthop. 2008 Apr-May;28(3):352-8.
     
  27. Bug

    Bug Well-Known Member

    Birth history - prematurity, low birth weight, TEV etc are risk factors for CP or Sensory integration disorders (SID)
    History - trauma related
    Familial - CMT, MD, idopathic
    Neuro - reflexes, tone, quality of muscle movement - for CP
    Biomech - equinus involvement
    Behavioural - autism, SID

    Am currently working on tool to help clinicians with this based on the evidence. Stay tuned....
     
  28. Boots n all

    Boots n all Well-Known Member

    Always do Bug....
     
  29. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Detecting Idiopathic toe-walking gait pattern from normal gait pattern using heel accelerometry data and Support Vector Machines.
    Pendharkar G, Lai DT, Begg RK.
    Conf Proc IEEE Eng Med Biol Soc. 2008;1:4920-4923.
    Department of Electrical and Computer Systems Engineering, Monash University, Melbourne 3168, Australia.
     
  30. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Persistent Toewalking in Autism.
    Barrow WJ, Jaworski M, Accardo PJ.
    J Child Neurol. 2011 Jan 31. [Epub ahead of print]
     
  31. footfan

    footfan Active Member

Loading...

Share This Page