Hi all,
Members do not see these Ads. Sign Up.
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???
<
Bone scans in children with obscure foot pain
|
Help wiith diagnosis: 8 yo male asymptomatic unilateral forefoot plantar anhydrotic skin.
>
-
-
Just out of interest, does the subject have any older siblings?
-
yeah an older sister who toe walked for about 2 months but grew out of it and is asymptomatic
-
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 -
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! -
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! -
-
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. -
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. -
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. -
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
-
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). -
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
-
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 -
Hi Simon,
why articulating AFO's?
ta
Declan -
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 -
would your criteria remain similar with gastroc tightness
ta
Declan -
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 -
Do we not get best stretch on gastrocs in 3rd rocker in gait when extension moment is greatest?
Sorry, drifting off topic
Dec -
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
-
Dito,
Byond 3yoa raises concerns.
Dig deep,
PB -
Have you thought of chirporactic to ensure muscles are being innervated properly?
-
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.
-
What are all the assessments we should be doing when a toe walker somes into the clinic?
-
2. Neuro assessment (eg cerebral palsy)
3. Behavioural history (eg autism)
4. Bioeval (eg limited RoM) -
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.
-
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.... -
-
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.
-
Persistent Toewalking in Autism.
Barrow WJ, Jaworski M, Accardo PJ.
J Child Neurol. 2011 Jan 31. [Epub ahead of print]
-
I know this is late but the pain may have possibly been from trigger points in the gastroc see here http://www.latrobe.edu.au/podiatry/myofasc/gastrocnemius.html
<
Bone scans in children with obscure foot pain
|
Help wiith diagnosis: 8 yo male asymptomatic unilateral forefoot plantar anhydrotic skin.
>
Loading...
- Similar Threads - Habitual toe walker
-
- Replies:
- 2
- Views:
- 1,718
-
- Replies:
- 0
- Views:
- 2,499
-
- Replies:
- 73
- Views:
- 19,268
-
- Replies:
- 0
- Views:
- 332
-
- Replies:
- 0
- Views:
- 228
-
- Replies:
- 1
- Views:
- 271
-
- Replies:
- 0
- Views:
- 294