Is Idiopathic Toe Walking Really Idiopathic?

NewsBot · Jan 30, 2013

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Is Idiopathic Toe Walking Really Idiopathic? The Motor Skills and Sensory Processing Abilities Associated With Idiopathic Toe Walking Gait.
Williams CM, Tinley P, Curtin M, Wakefield S, Nielsen S.
J Child Neurol. 2013 Jan 24

This study aimed to investigate any differences between the motor skills and sensory processing abilities of children between the ages of 4 and 8, who do and do not have an idiopathic toe walking gait. Children in each cohort were tested with a number of norm referenced assessments. A total of 60 children participated, 30 within each cohort. Those with an idiopathic toe walking gait were found to have different Sensory Profile quadrant scores (P = .002), poorer performance on the Bruininks-Oseretsky Test of Motor Proficiency (P ≤ .001), a lower vibration perception threshold (P = .001), and poorer performance on the Standing Walking Balance subtest of the Sensory Integration and Praxis Test (P = .047), compared with non-toe walking peers. Although this research does not give a causative factor for toe walking gait, it provides a number of theories as to why this gait may not be idiopathic in nature.
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Admin2 · Jan 30, 2013

Related threads:
Other threads tagged with toe walking
Neuropsychiatric symptoms and problems among children with idiopathic toe-walking
The Prevalence and Course of Idiopathic Toe-Walking in 5-Year-Old Children
Toe Walking
Toe walking
Motor control intervention for toe walking
Idiopathic toe walking and sensory processing dysfunction

NewsBot · Jun 9, 2013

The foot and ankle characteristics in children with idiopathic toe walking gait
Cylie Williams, Paul Tinley, Michael Curtin and Sharon Nielsen
Journal of Foot and Ankle Research 2013, 6(Suppl 1):O39 doi:10.1186/1757-1146-6-S1-O39

Background
Idiopathic toe walking (ITW) has been associated with ankle equinus, and while equinus has been linked with foot deformity in adults, there has been limited investigation on its impact on structural foot change in children. This study used the weight bearing lunge (WBL) test and Foot Posture Index-6 (FPI-6) to evaluate the foot and ankle measures of children with an ITW gait.

Methods
Sixty children between the ages of four and eight years were grouped into an ITW (N=30) and a non-toe walking (NTW) (N=30) cohort. The ankle range of movement and FPI-6 was calculated during appropriate weight–bearing test and stance.

Results
There was a highly significant difference in the WBL test measures between the ITW cohort and the NTW cohort. The FPI-6 comparison was not significant. The WBL test was also not predictive of an abnormal FPI-6 in the ITW cohort.

Conclusion
These results demonstrate that ITW gait style impacts only on the available dorsiflexion at the ankle. The WBL measure may be utilised within the clinical setting to guide and monitor treatment interventions.
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NewsBot · Sep 7, 2013

NewsBot · Sep 27, 2013

Foot and Ankle Characteristics of Children with an Idiopathic Toe-Walking Gait
Cylie Williams, BASci (Pod), MHSci (Hlth Ed & Prom), PhD*, Paul D. Tinley, PhD†, Michael Curtin, BOccThy, MPhil, EdD‡ and Sharon Nielsen, BAppSc, DipEd, Grad Cert Biom, MPhil§
J Am Podiatr Med Assoc 103(5): 374–379, 2013

Background: Idiopathic toe-walking (ITW) in children has been associated with ankle equinus. Although equinus has been linked to foot deformity in adults, there has been limited investigation of the impact of equinus on structural foot change in children. We used the weightbearing lunge test and the six-item version of the Foot Posture Index (FPI-6) to evaluate the weightbearing foot and ankle measures of children with an ITW gait and to compare these with their age-matched peers.

Methods: Sixty 4-to 6-year-old children were grouped into ITW (n = 30) and non–toe-walking (n = 30) cohorts using a validated ITW tool. Ankle range of motion was determined with weightbearing lunge tests. The FPI-6 was calculated during weightbearing stance.

Results: There was a highly significant difference in the weightbearing lunge test measures between the ITW cohort and the non–toe-walking cohort. The FPI-6 comparison was not significant. The straight-leg lunge test had a statistically significant relationship with the FPI-6 in the ITW cohort.

Conclusion: Children with an ITW gait demonstrated reduced flexibility at the ankle joint but similar weightbearing foot posture compared with non–toe-walking children, showing that for children 4 to 8 years old, an ITW gait affects the available ankle dorsiflexion but seems to have a limited effect on weightbearing foot posture as measured by the FPI-6.
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NewsBot · Jan 16, 2014

Outcome after conservative and operative treatment of children with idiopathic toe walking: a systematic review of literature
A. F. van Bemmel, V. A. van de Graaf, M. P. J. van den Bekerom, D. A. Vergroesen
MUSCULOSKELETAL SURGERY; January 2014

When toe walking persists after the age of 2 years in the absence of any neurological or orthopedic abnormalities, it is referred to as idiopathic toe walking (ITW). When the plantar flexion persists, an equinus contracture can develop. There is inconsistency in the treatment of choice of this condition. A systematic review of observational studies comparing cast and operative treatment of children with ITW or equinus contracture was undertaken. Ten trials involving 298 participants were included. Ankle dorsiflexion increased 3.1° (median follow-up 3 years) in the cast treatment group and 14.2° (median follow-up 3.3 years) in the surgical group. No significant differences between groups were found in terms of persistent toe walking and complications after treatment. We have found favorable results in improvement of dorsiflexion for children treated by surgery. However, due to heterogeneity of patient groups, sample size and follow-up, no firm conclusions on a favorable role of surgery or cast treatment could be drawn in the treatment of ITW or equinus contracture.
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David Smith · Jan 16, 2014

NewsBot said: ↑

Is Idiopathic Toe Walking Really Idiopathic?24[/URL]
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Yes of course it is, the question is self defining. Idiopathic means arising from an unknown cause, a disease having an unknown cause. Therefore once a disease's cause is discovered then it is no longer unknown:dizzy:

Dave

NewsBot · Jun 6, 2014

Idiopathic Toe-Walking.
Cylie M. Williams, Paul Tinley, and Barry Rawicki
Journal of the American Podiatric Medical Association: May 2014, Vol. 104, No. 3, pp. 253-262.

Background: Idiopathic toe-walking (ITW) is a condition commonly seen by podiatric physicians. Because a toe-walking gait style is also caused by or associated with many other medical conditions, podiatric physicians should pay particular attention to ensuring an accurate diagnosis. There are many reported treatment options available for ITW. Therefore, a literature review was conducted to determine what treatment options are supported by the evidence as having the best long-term effect on ITW gait.

Methods: After extraction of relevant articles, 21 manuscripts reporting treatment options for ITW gait were appraised against the levels of evidence.

Results: From these articles, there was no single treatment option reported as having a long-term effect on the gait of children with ITW. There was support in the literature for surgical interventions, serial casting, and the use of botulinum toxin type A. There was limited evidence that footwear or orthoses changed the gait pattern.

Conclusions: This review updates the knowledge of podiatric physicians, enhances how children who present with this gait style can be managed, and highlights areas for future research.
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NewsBot · Jun 30, 2014

Can pediatric idiopathic toe walking be associated with delays in language?
Stephanie Pascoe
University of Western Ontario: School of Communication Sciences and Disorders

This critical review examines the current research on the association between idiopathic toe
walking and language delay. A completed literature search using computerized databases and
examination of the retrieved articles yielded four studies. Overall, the literature review
revealed an association between idiopathic toe walking and language delays, supporting
idiopathic toe walking as a marker for developmental problems. Clinical implication and
recommendations for future research are discussed.
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NewsBot · Jan 21, 2016

A Comparison of the Birth Characteristics of Idiopathic Toe Walking and Toe Walking Gait Due to Medical Reasons
Stephanie Baber, BPTAdvRes(Hons), Joanne Michalitsis, BSc, BAppSc(Pod), Michael Fahey, MBBS (Hons), PhD, FRACP, Barry Rawicki, MBBS, FAFRM(RACP), FACRM, Terry Haines, BPhysio(Hons), GradCertHlthEcon, PhD, Cylie Williams, BAppSc (Pod), MHlthSci(HlthEd&Prom), PhD
The Journal of Pediatrics; 16 January 2016

Objective
To determine and compare the birth history or postnatal complications of idiopathic toe walking (ITW) and toe walking known to be associated with a medical condition.

Study design
This was a retrospective chart review of parent-reported birth histories of children who presented to a dedicated toe-walking clinic between 2010 and 2014. This cohort comprised children diagnosed with ITW and children with a medical reason for their toe-walking gait. Data were compared with Australian Perinatal statistical normative data.

Results
Ninety-five children (60 males, 63%) were diagnosed with ITW, with a mean (SD) age of 5.8 (2.9) years. Children with an ITW gait were found to have greater rates of prematurity (OR 2.4; 95% CI 1.43-4.03), greater rates of admission to a special care nursery or neonatal intensive care unit (OR 1.98; 95% CI 1.23-3.18), and lower birth weights (OR 6.6; 95% CI 3.48-12.5) than the normative population. Children with a medical reason for toe walking (n = 28, 68% males) also had greater rates of prematurity (OR 2.4; 95% CI 0.94-6.09) than the normative population and more instrumented births than the ITW cohort (OR 1.56; 95% CI 0.64-3.77). No association was found between assisted-birth intervention and the ITW cohort compared with the normative population or group with a medical cause for toe walking.

Conclusions
ITW gait was associated with greater rates of complications during and after delivery. Such complications have been associated previously as risk factors for neurologic insult affecting motor development.
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NewsBot · Feb 13, 2016

Idiopathic Toe Walking
Tests and Family Predisposition
David Pomarino et al
Foot Ankle Spec February 12, 2016

The aim of this study is to provide clinical examination methods that were designed specifically to assess the level of severity among children with idiopathic toe walking (ITW). The idiopathic toe-walking pattern of 836 children was recorded and analyzed during 4 years. Questionnaires and clinical measurements were evaluated, along with differential tests, assessing the occurrence and severity of toe walking. Questions about family history and onset of toe walking were evaluated along with special tests and measurements assessing the occurrence and severity of toe walking. The different measurements apply during this study, ankle dorsiflexion, lumbar lordosis angle, as well as the clinical spin test, walking after spin test, and heel walking test revealed in all cases that children with a positive family predisposition were significantly more affected than children with negative family predisposition. It is concluded that children with ITW and a positive family predisposition were more intensively affected during all performed clinical tests than children with no family predisposition. The tests used during this study have not being used by any other researches, even though they showed significant differences between the children with ITW and children with a normal gait pattern.
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NewsBot · Feb 20, 2016

Effect of a nonsurgical treatment program on the gait pattern of idiopathic toe walking: a case report
Szopa A, Domagalska˗Szopa M, Gallert˗Kopyto W, Kiebzak W, Plinta R
Therapeutics and Clinical Risk Management ? Volume 12

Background: Recent studies have reported many possibilities for the treatment of idiopathic toe walking (ITW); however, none of them have been sufficiently documented. The purpose of this case study was to document the evolution of the gait pattern of a child with severe ITW using the Gillette Gait Index before and after the third and sixth weeks, a nonsurgical treatment program and then every 3 months to 1 year from the start of the treatment. This is significant because the case study shows that a nonsurgical treatment program can be an alternative treatment method for children with severe ITW.
Case description: The case study involved a 5-year-old boy diagnosed with severe ITW. An orthopedist recommended a surgical treatment, but his parents refused to provide consent.
Intervention: The subject participated in a 12-week nonsurgical treatment program that used tone-inhibiting casts (TICs) combined with physiotherapy based on neurodevelopmental treatment principles. The treatment protocol included the following: 1) precast preparation; 2) TICs with treatment; and 3) post-cast treatment to improve the gait pattern.
Outcomes: After treatment with TICs, the range of motion of ankle dorsiflexion during stance had increased, resulting in an almost normalized gait. The patient stopped toe walking for at least 1 year.
Discussion: This study demonstrates that nonsurgical treatment should be considered first, with surgical options reserved for resistant cases; however, further research is required given the current lack of knowledge about treatment outcomes using TICs and the wide use of this treatment modality in children with ITW.
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NewsBot · Feb 27, 2016

Distal Vibration Perception Threshold in Children Who Toe Walk.
Ganley, Kathleen J. PT, PhD; Behnke, Claire PT, DPT
Pediatric Physical Therapy: February 19, 2016

Purpose: To compare distal vibratory perception threshold and sensation in children who toe walked (TW) and controls.

Methods: Vibration perception threshold was measured at the metacarpal and metatarsal phalangeal (MCP and MTP) joints in 11 TW and 15 age-matched controls. Mean vibratory threshold (MVT) was calculated for each site; a Pearson correlation coefficient was determined for MVT at MCP and MTP joints. Groups were compared using a Mann-Whitney U test. Parent/caregiver responses on the Short Sensory Profile (SSP) were compared using a [chi]2 test.

Results: MVTs at the MCP and MTP joints were highly correlated in both groups. MVT was higher in TW compared with controls at each site. Children who TW were more likely to have a total SSP score in the "probable difference" or "definite difference" categories compared with the "no difference" category.

Conclusion: Sensation should not be overlooked in the evaluation and clinical management of toe walking.
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NewsBot · Mar 15, 2016

Blog post:
Why Toe Walking Is NOT Idiopathic

NewsBot · Apr 15, 2016

Pediatric Toe Walking: Beyond Muscles And Bones!

NewsBot · Apr 19, 2016

Neurodevelopment in preschool idiopathic toe-walkers.
Mart?n-Casas P et al
Neurologia. 2016 Apr 14

INTRODUCTION:
Idiopathic toe walking, a differential diagnosis for neurological and orthopaedic disorders, has been associated with neurodevelopmental alterations. Neurodevelopmental assessment at early ages using specific tests may improve management and follow-up of these patients. The aim of our study is to analyse the neurodevelopmental characteristics of preschool idiopathic toe-walkers (ITW) by comparing them to a control group.
METHOD:
Our descriptive cross-sectional study compared possible risk factors, neurodevelopmental characteristics, and scores on the Child Neuropsychological Maturity Questionnaire (CUMANIN) between a group of 56 ITWs aged 3 to 6 and a control group including 40 children.
RESULTS:
The proportion of males was significantly higher in the ITW group (P=.008). The percentage of patients with a family history (P=.000) and biological risk factors during the perinatal period (P=.032) was also higher in this group. According to the parents' reports, motor coordination in ITWs was significantly poorer (59%; P=.009). ITWs scored significantly lower on CUMANIN subscales of psychomotricity (=0,001) and memory (P=.001), as well as in verbal development (P=.000), non-verbal development (P=.026), and overall development (P=.004). Foot preference was less marked in the ITW group (P=.047).
CONCLUSIONS:
The neurodevelopmental characteristics of our sample suggest that idiopathic toe walking is a marker of neurodevelopmental impairment. However, further studies are necessary to confirm these findings.
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NewsBot · Jun 7, 2016

Study Identifies Alternative Treatment for Idiopathic Toe Walking

HansMassage · Jun 20, 2016

It tends to be idiopathic to most providers because they have not studied the reflexes inherent in altered posture. I repeatedly find unilateral toe walking with a fixed spinal rotation. usually the spinal rotation is compensated with a pelvic rotation and compensatory apparent short leg compensated by the toe walking. Bilateral toe walking is usually compensation for a fixation of the center of gravity too far forward just as heel walking is compensation for fixation of the center of gravity too far back.

NewsBot · Jul 2, 2016

Idiopathic Toe Walking
Family Predisposition and Gender Distribution
David Pomarino et al
Foot Ankle Spec July 1, 2016

Current literature is inconsistent concerning the causes and the frequency of idiopathic toe walking (ITW). Available studies vary widely in their results. The aim of this study is to supply gender-related data particularly regarding the genetic influence on toe walking. Methods. The ITW patterns of 836 children were recorded and analyzed during a period of 4 years. Questionnaires and clinical measurements were evaluated along with clinical tests, assessing the occurrence and severity of toe walking. Information about the incidence of toe-walkers in the family was recorded. Results. Of the 836 toe-walkers, 64% were boys and 42% had a positive family history (PF-TW). About 60% of the PF-TW children had fathers with a positive toe-walking pattern. PF-TW children were on average half a year younger than children with a negative family predisposition (NF-TW). Conclusions. This study shows that a genetic component might be factor in toe walking. PF-TW children were more severely affected in all performed clinical tests than NF-TW children.
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NewsBot · Jul 27, 2016

What it means when kids walk on their toes

NewsBot · Sep 20, 2016

The 3-Step Pyramid Insole Treatment Concept for Idiopathic Toe Walking
David Pomarino et al
Foot Ankle Spec September 19, 2016

The idiopathic toe walking (ITW) gait pattern is characterized in children for walking since the beginning on their first steps on the forefoot; however, these children are able to support their whole foot on the ground. ITW can only be diagnosed in the absence of any orthopaedic or neurological condition known to cause tiptoe walking. The aim of this article is to review other references and provide an outline of the different treatment options, including the 3-step-pyramid insole treatment concept for children with ITW. Methods. Fifty-four articles in English, German, and Spanish were reviewed. There were comparative, retrospective or case studies, classifications or literature reviews and they were divided according with these categories. All the literature reviewed was published between 2000 and 2015. Results. There are some studies that proved the 3-step pyramid insole treatment concept as an effective option compared with other therapeutic modalities such as physical therapy, casting, botolinum toxin type A (BTX), and surgery. Conclusion. There is a wide spectrum regarding the therapeutic options for children with ITW, from physical therapy to surgery options. However, any of these treatment modalities have been reported to be fully successful for the whole toe walking population. Some procedures seem to have achieved faster results or seem to have longer lasting effects. Therefore, further research on the causes of ITW is recommended.
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NewsBot · Sep 23, 2016

Toe walking as a presenting sign of systemic lupus erythematosus.
Basiaga M, Sherry D.
Lupus. 2015 Oct;24(12):1335-7. doi: 10.1177/0961203315586825

Toe walking is a previously unreported presentation of systemic lupus erythematosus (SLE). We describe a patient who presented with profound multisystem involvement that was preceded by one month of toe walking and multiple flexion contractures without arthritis. Her lupus is now under control after aggressive therapy, yet she continues to struggle with tendinopathy despite continued physical and occupational therapy. Lupus should be considered in the appropriate clinical context in children who have new-onset contractures due to tight tendons.
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NewsBot · Jan 18, 2017

Literature Review of Idiopathic Toe Walking.
Pomarino D et al
Foot Ankle Spec. 2017 Jan 1:1938640016687370. doi: 10.1177/1938640016687370.

PURPOSE:
The main objective of this review is to gather the information available about idiopathic toe walking (ITW), its prevalence and classification, and possible therapeutic approaches. In addition, this review aims to clarify the differences between idiopathic toe walkers and tiptoe walkers with underlying neurological or muscle deficiency as primary conditions. Understanding its causes and learning to make a differential diagnosis will help determine the adequate therapeutic approach.
METHODS:
This is a review of different articles and case studies from 1967 to 2016. The information was gathered to update and unify all the information about ITW that has been published.
CONCLUSION:
The literature offers limited research regarding the possible etiology, prevalence, classification, and evaluation of ITW. This review puts together all the information regarding the etiology, prevalence, classifications, evaluation, and treatment of ITW.
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NewsBot · Feb 21, 2017

Dynamic pedobarographic classification of idiopathic toe-walkers for therapeutical indication
Patricia Martín-Casas et al
Clínica y Salud; 17 February 2017

Idiopathic toe-walkers (ITWs) pedobarographic analysis has not been described yet nor its possible relationship with orthopedical and developmental characteristics. The objective of this research is to develop a dynamic pedobarographic classification of ITWs to propose a specific therapeutical approach. Through an observational study, 56 ITWs aged 3-6 years were classified by their initial foot contact; differences between idiopatic toe-walking (ITW) types and with respect to 40 control children were calculated by means of ANOVA and Student t-tests. The results show that the three ITW types displayed different step models for pressure and impulse distribution and also for temporal development (p < .05). They also showed different orthopedic and developmental characteristics (p < .05). As a whole, they demonstrated different severity levels, which suggest different therapeutical indications. This study confirms the convenience of a specific orthopedic, developmental, and gait assessment in ITW to clarify therapeutical indication.
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NewsBot · Feb 28, 2017

IDIOPATHIC TOE WALKING AND POSTURAL INSTABILITY: THE NEXT STEP
JESSICA J. McHUGH, B.A., M.S.
Phd Thesis; 2016

PURPOSE: The purpose of this study was to compare the proprioceptive system and
postural control of children who walk on their toes and children who do not exhibit this
gait pattern. The study had two objectives: 1) determine if children who exhibit an
idiopathic toe walking (ITW) gait pattern exhibit differences in four positions when
compared to non-toe walking peers, and 2) determine if there is a difference in response
to everyday sensory challenges as reported by parents using the Sensory Processing
Measure Home Form (SPM-Home) or Sensory Processing Measure-Preschool Home
Form (SPM-P Home).
METHODS: Idiopathic toe walkers (n=15) and controls matched for age and gender
(n=15) were evaluated using the following clinical observations: Schilder’s arm extension
test, wall squat, supine flexion, and prone extension along with the SPM-Home or SPM-P
Home in order to determine differences in sensory processing, namely proprioception and
postural control.
RESULTS: Significant differences were found between idiopathic toe walkers and nontoe
walking peers in three postural control positions: wall squat (p=.003), supine flexion
(p=.026), and prone extension (p=.021). The final postural control position, Schilder’s
Arm Extension arm position, revealed significant differences in arm position (p=.049)
and disassociation approached significance (p=.062). There were no significant
differences in any of the subtests of the SPM-Home and SPM-P Home when comparing
idiopathic toe walkers and non-toe walkers.
CONCLUSION: This study indicates that difficulties with proprioception, namely
postural control, may be factors in children with an ITW gait pattern. This research
contributes to the growing body of knowledge related to ITW with a specific focus on
proprioceptive systems input to ITW
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NewsBot · Apr 4, 2017

Validity of an Accelerometer Used to Measure Step Count in Children With Idiopathic Toe Walking
Christensen, Catie PT, DPT; Haddad, Amanda PT, DPT; Maus, Elizabeth PT, DPT, PCS
Pediatric Physical Therapy: April 2017 - Volume 29 - Issue 2 - p 153–157

Purpose: To assess the validity of accelerometer use in children with idiopathic toe walking (ITW).

Methods: Seventy-five children, 2 to 13 years old, with ITW were videotaped ambulating 50 ft wearing a NL-1000 accelerometer. Because of concerns for accelerometer accuracy in young children, 2 groups were created: 5 years or younger (n = 45) and 6 years or older (n = 30). Step counts recorded via accelerometer and video were compared and correlated.

Results: There was a significant difference in accelerometer and video step counts for 2- to 5-year-olds (W = 72.00, P < .001). No significant difference was found for 6- to 13-year-olds (W = 65.00, P = .24). Spearman ρ values were 0.78 and 0.92 for the 5 years or younger and 6 years or older groups, respectively.

Conclusion: Accelerometers accurately count steps in 6- to 13-year-olds with ITW but are inaccurate in 2- to 5-year-olds.
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NewsBot · Jul 14, 2017

Validity of an Accelerometer Used to Measure Step Count in Children With Idiopathic Toe Walking.
Christensen C et al
Pediatr Phys Ther. 2017 Apr;29(2):153-157. doi: 10.1097/PEP.0000000000000364.

PURPOSE:
To assess the validity of accelerometer use in children with idiopathic toe walking (ITW).
METHODS:
Seventy-five children, 2 to 13 years old, with ITW were videotaped ambulating 50 ft wearing a NL-1000 accelerometer. Because of concerns for accelerometer accuracy in young children, 2 groups were created: 5 years or younger (n = 45) and 6 years or older (n = 30). Step counts recorded via accelerometer and video were compared and correlated.
RESULTS:
There was a significant difference in accelerometer and video step counts for 2- to 5-year-olds (W = 72.00, P < .001). No significant difference was found for 6- to 13-year-olds (W = 65.00, P = .24). Spearman ρ values were 0.78 and 0.92 for the 5 years or younger and 6 years or older groups, respectively.
CONCLUSION:
Accelerometers accurately count steps in 6- to 13-year-olds with ITW but are inaccurate in 2- to 5-year-olds.
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NewsBot · Oct 3, 2017

Differentiating Between Idiopathic Toe Walking and Cerebral Palsy: A Systematic Review
Lindsey Adelstein, SPT, Mary Claire Hartford, SPT, Bernadette Javier, SPT; Rachel Kern, SPT; Marley Owen,
SPT; Kerryn St. Andre, SPT, Kathleen Schlough, PT, DSc, PhD
source

Background: Toe walking is defined as the absence or inability to obtain heel strike during the initial
contact and stance phases of the gait cycle1
. Many developing toddlers tend to walk with a wide base of
support, externally rotated hips, flexed knees and plantarflexed feet2
. Toe walking is considered a typical
part of a developing gait pattern but begins to be considered abnormal past the age of three years3
. Toe
walking can occur with various diagnoses, such as Cerebral Palsy, Autism Spectrum Disorder, Muscular
Dystrophy or Spina Bifida4
. However, when no other orthopedic, musculoskeletal, or neurological
condition that can cause this gait pattern can be identified, a diagnosis of Idiopathic Toe Walking (ITW)
is given. The purpose of this systematic review is to provide a comparison of the gait characteristics and
muscle firing patterns in children with a diagnosis of ITW and Mild Spastic Diplegia (MSD), a type of
Cerebral Palsy. Mild Spastic Diplegia is a neurological condition that is characterized by muscle
weakness, changes in muscle tone, and and impaired selective motor control. The lower extremities are
more affected, which leads to deficits in functional mobility. MSD can be often confused with ITW due to
similarities in gait patterns. The authors identified 5 studies that compared gait patterns and muscle firing
patterns in children with MSD and ITW.
Methods: The authors searched four databases between the dates of September 13-28, 2016, which
included PubMed, CINAHL, SPORTDiscus, and Medline. The following search terms were utilized for
each database: (Idiopathic Toe Walking and Cerebral Palsy), (Idiopathic Toe Walking and Spastic
Diplegia), (Habitual Toe Walking and Cerebral Palsy), and (Habitual Toe Walking and Spastic Diplegia).
Articles were included if they met the following inclusion criteria: a diagnosis of ITW or MSD, including
subjects between the ages of 3-18 in ITW group and 2-18 in MSD group, and did not include subjects
with comorbid conditions previously identified to cause toe walking. Articles were excluded if they
primarily discussed physical therapy intervention for ITW or primarily discussed medical intervention for
ITW. After thorough review of the research, five articles remained that met our inclusion and exclusion
criteria.
Results: Two of the studies looked at kinematic variables in children with ITW and MSD. Both authors
concluded that knee kinematics were normal in the ITW group3,5. However, children with MSD presented
with increased knee flexion angles, presumably due to increased hamstring tone. Children with ITW
showed increased plantarflexion at initial contact and active muscle contraction of their gastrocnemius
muscles during swing phase, causing them to strike in an equinus position3
. This differed from the pattern
of children with MSD. The children with MSD also demonstrated increased plantarflexion at initial
contact, but this was because of an increase in knee flexion, which changed the position of the foot. This
did not allow the child to contact the ground with the mid or rearfoot3,5. There were three studies that
utilized electromyography to look at differences in muscle timing between children with ITW, MSD, and
typically developing children. All articles agree that there were no significant differences in muscle firing
between ITW and MSD during gait6,7,8. Children with MSD demonstrate an obligatory extensor synergy,
which causes coactivation of the quadriceps and gastrocnemius muscles during isometric knee
extension7,8. This is not seen in children with ITW and children without neurological deficits. This is
clinically significant because it may allow physical therapists to differentiate between children with ITW
and MSD using surface electromyography or palpation during resisted knee extension.
Discussion and Conclusions: Because ITW is a diagnosis of exclusion, there are limited tests and
measures that clinicians can utilize. Clinically, the results of this systematic review can be used to help
differentiate between a diagnosis of ITW and MSD. Clinicians can perform a simple examination,
including gait analysis and electromyography or palpation during resisted contraction, to help
differentiate between ITW and MSD. It is important for clinicians to be able to make this differentiation,
because the two conditions are treated differently. Early detection of the correct cause for toe walking can
increase access to both physical therapy and medical interventions, which may greatly improve the child’s
prognosis.
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NewsBot · Dec 2, 2017

PowerPoint:
Idiopathic toe walking:
a multidisciplinary approach

NewsBot · Jan 7, 2018

Reliability and Validity of the 50-ft Walk Test for Idiopathic Toe Walking.
Christensen C, Haddad A, Maus E.
Pediatr Phys Ther. 2017 Jul;29(3):238-243. doi: 10.1097/PEP.0000000000000399.

PURPOSE:
To evaluate interrater reliability and concurrent validity of the 50-ft walk test (FWT) for children with idiopathic toe walking (ITW).

METHODS:
Thirty children, 6 to 13 years old, with ITW participated. During the 50-FWT, an accelerometer counted total steps. A physical therapist counted the number of toe-walking steps. The number of toe-walking steps was divided by the total steps to calculate a toe-walking percentage. Interrater reliability was assessed by correlating the toe-walking percentage obtained by 2 raters using an intraclass correlation coefficient. Concurrent validity was evaluated by correlating the toe-walking percentage calculated by the GAITRite and therapist using a Spearman ρ.

RESULTS:
There was excellent interrater reliability and concurrent validity. Experience level did not impact the therapist's ability to identify a toe-walking step.

CONCLUSIONS:
The 50-FWT demonstrated excellent interrater reliability and concurrent validity. It can be used to obtain a percentage of toe walking in children 6-13 years of age with ITW.
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NewsBot · Jan 9, 2018

Toe Walking: A Neurological Perspective After Referral From Pediatric Orthopaedic Surgeons
Haynes Katherine B. MPAS PA-C; Wimberly, Robert L. MD; VanPelt, Jonathan M. BS, MHA; Jo, Chan-Hee PhD; Riccio, Anthony I. MD; Delgado, Mauricio R. MD
Journal of Pediatric Orthopaedics: January 05, 2018

Background:
Toe walking (TW) in children is often idiopathic in origin. Our purpose was to determine the incidence of a neurological etiology for TW in patients seen in the neurology clinic after referral from pediatric orthopaedic surgeons.

Methods:
We performed an Institutional Review Board approved retrospective review of 174 patients referred to the neurology clinic from orthopaedic surgeons at an academic pediatric tertiary care center between January 2010 and September 2015. Medical records were reviewed and data recorded including pertinent family history, birth history, age of initial ambulation, physical examination findings, and workup results including neuroimaging, neurophysiological studies, and findings of genetic testing and tissue biopsy.

Results:
Sixty-two percent (108/174) of patients were found to have a neurological etiology for TW. Final pathologic diagnoses were: 37% (40/108) previously undiagnosed cerebral palsy (CP), 16.7% (18/108) peripheral neuropathy, 15.7% (17/108) autism spectrum disorder, 13.9% (15/108) hereditary spastic paraparesis, 8.3% (9/108) attention deficit hyperactivity disorder, 5.6% (6/108) syndromic diagnosis, and 2.8% (3/108) spinal cord abnormality. Ankle equinus contractures were noted in idiopathic and neurological patients and did not indicate a pathologic origin. Seventy-one percent of unilateral toe walkers and 32% of bilateral but asymmetric toe walkers were diagnosed with CP (P<0.001). Twenty-six percent of 145 brain magnetic resonance imaging studies diagnosed CP. Of the 125 (72%) with spinal imaging, 3 had spinal pathology to account for TW. Fourteen percent of 87 subjects with an electromyography/nerve conduction study had abnormal results indicating a peripheral polyneuropathy.

Conclusions:
An underlying pathologic diagnosis was found in 62% of patients referred to neurology for TW. A concerning birth history, delayed initial ambulation, unilateral TW, upper or lower motor neuron signs on examination, or behavioral features may suggest a pathologic diagnosis. Ankle contracture is not predictive of an abnormal diagnosis and can be found in idiopathic patients. CP, peripheral neuropathy, autism spectrum disorder, and hereditary spastic paraparesis are the most common pathologic diagnoses identified in our population.
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NewsBot · Feb 16, 2018

Long-term Gait Outcomes Following Conservative Management of Idiopathic Toe Walking
Karen Davies et al
Gait and Posture; Article in Press

Highlights
•Long-term follow-up study of children with idiopathic toe walking.
•3-D gait outcomes and toe walking severity were explored with or without casting.
•Kinematic and kinetic timing and ankle power improved in both groups at follow-up.
•Kinematics and toe walking severity improved in the cast group only at follow-up.
•Participation was unrestricted by self-report at follow-up.
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Background
Idiopathic toe walking is a diagnosis of exclusion characterized by a persistent toe-toe gait pattern after three years of age. Treatment for toe walking includes physical therapy, orthotics, casting, Botulinum Toxin A injection into gastrocnemius/soleus muscles, and/or surgery; yet, little evidence exists regarding long-term treatment effects.

Research Question
The objective of this study was to explore the differences in longer-term gait outcomes and severity of idiopathic toe walking between children treated actively with casting or inactively following recommendations for stretching.

Methods
Forty-three adolescents and young adults (14.3-28.8 years; 21 females, 22 males) who had participated in an idiopathic toe walking classification study as children, returned for repeat physical examination and three-dimensional computerized gait analysis (13.4 years follow-up, range 9.4-17.8 years); 23 participants had received active treatment with casting and ankle foot orthotics +/− Botulinum Toxin A injection as children and 20 participants had received inactive treatment with recommended stretching exercises. Gait analysis data were compared retrospectively from baseline to follow-up using analysis of variance; toe walking severity was compared using a Wilcoxin Signed-Rank Sums test.

Results
Ankle angle at initial contact, peak dorsiflexion in stance, and toe walking severity improved significantly in the active treatment group only at follow-up. Significant improvement in peak ankle power and timing of ankle kinematics and kinetics in the gait cycle were found in both groups; however, greater changes occurred in the active treatment group. Both groups showed significantly improved internal plantar flexor moments, whereas knee extension increased in stance and passive ankle dorsiflexion decreased in both groups at follow-up (p = 0.001). Intermittent toe walking was reported in 49% (21/43) of participants at follow-up.

Significance
The results of this study suggest that improvement in ankle kinematic timing and ankle kinetic gait analysis variables is sustainable, independent of conservative treatment for idiopathic toe walking in childhood.
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NewsBot · Mar 25, 2018

Feedforward neural control of toe walking in humans.
Lorentzen J et al
J Physiol. 2018 Mar 23

Toe walking requires careful control of the ankle muscles in order to absorb the impact of ground contact and maintain a stable position of the joint. The present study aimed to clarify the peripheral and central neural mechanisms involved. Fifteen healthy adults walked on a treadmill (3.0 km h-1 ). Tibialis Anterior (TA) and Soleus (Sol) EMG, knee and ankle joint angles and gastrocnemius-soleus muscle fascicle lengths were recorded. Peripheral and central contributions to the EMG activity were assessed by afferent blockade, H-reflex testing, Transcranial Magnetic Brain Stimulation (TMS) and sudden unloading of the planter flexor muscle-tendon complex. Sol EMG activity started prior to ground contact and remained high throughout stance. TA EMG activity, which is normally seen around ground contact during heel strike walking, was absent. Although stretch of the Achilles tendon-muscle complex was observed after ground contact, this was not associated with lengthening of the ankle plantar flexor muscle fascicles. Sol EMG around ground contact was not affected by ischemic blockade of large diameter sensory afferents, or the sudden removal of ground support shortly after toe contact. Soleus motor evoked potentials elicited by TMS were facilitated immediately after ground contact, whereas Sol H-reflexes were not. These findings indicate that at the crucial time of ankle stabilisation following ground contact, toe walking is governed by centrally mediated motor drive rather than sensory driven reflex mechanisms. These findings have implications for our understanding of the control of human gait during voluntary toe walking.
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NewsBot · Mar 28, 2018

Outcomes of Noninvasively Treated Idiopathic Toe Walkers.
Radtke K et al
Foot Ankle Spec. 2018 Mar 1:1938640018766609.

Idiopathic toe walking (ITW) causes a common problem in pediatric orthopaedics. In the literature, numerous treatment options have been reported, but consensus about the management of ITW is still missing. The aim of the current study was to evaluate conservative treatment with pyramidal insoles. A total of 193 patients underwent conservative treatment between January 2010 and June 2013. Mean age at the beginning of the treatment was 7.75 ± 0.23 years (range 2.0-17.0 years). For all patients, demographic data, comorbid diseases, passive range of motion (ROM), persistent toe walking, and performed operations were retrospectively evaluated. Following operative treatment was defined failure. Eight (4.15%) patients underwent Achilles tendon lengthening operation after mean therapy time of 2.72 years (range 0.1-7.0 years), 174 cases were treated successfully (90.16%). In 50 cases, toe walking suspended completely after mean therapy time of 2.83 years. In cases of failure, patients were older at diagnosis and at the beginning of the treatment. Mean passive ROM increased over the time. In cases of failure, ROM decreased from the first to the second examination. Conservative treatment of ITW using pyramidal insoles can be effective. Ankle dorsiflexion significantly improved in the patients who were successfully treated. Therapy should start early. A decrease of ROM under therapy should lead to critical revisal of individual therapy.
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NewsBot · Mar 31, 2018

Soleus H-Reflex and Its Modulation With Vibration in Idiopathic Toe Walkers and Typically Developing Children
Essi Marttinen Rossi, MSc, Päivi Nevalainen, MD, PhD, Helena Mäenpää, MD, PhD, ...
Journal of Child Neurology March 26, 2018

Idiopathic toe walking is a relatively common developmental condition often leading to secondary problems such as pain and muscle contractures in the lower extremities. The cause of idiopathic toe walking is unknown, which hinders the development of treatment strategies. To test whether children with idiopathic toe walking have functional alterations in their spinal motor circuits, we studied the properties of the soleus H-reflex and its modulation with vibration in 26 idiopathic toe walkers and 16 typically developing children. At the group level, the H-reflex properties did not differ, but at the individual level, in 7 of 25 idiopathic toe walkers, some of the H-reflex parameters fell out of normal limits of typically developing children. However, the H-reflex was suppressed by vibration to the Achilles tendon similarly in both the idiopathic toe walkers and typically developing children. In conclusion, idiopathic toe walking in some children can be associated with functional alterations in their spinal motor circuits.
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NewsBot · Apr 26, 2018

Idiopathic Toe-Walking: Prevalence and Natural History from Birth to Ten Years of Age
Engström, Pähr; Tedroff, Kristina
JBJS: April 18, 2018 - Volume 100 - Issue 8 - p 640–647

Background: Children with idiopathic toe-walking, a common pediatric condition, walk some or all of the time on their toes. This condition often causes parental concern, with repeated medical contacts and a range of interventions including stretching, casts, injection of botulinum toxin A, and surgical procedures. The purpose of this cohort study was to document the natural history of this condition.

Methods: In a population-based cohort of 1,401 healthy 5.5-year-old Swedish children, we found the prevalence of idiopathic toe-walking to be approximately 5% (63 of 1,401). Of the 63 children who had ever been a toe-walker, 26 still were at the age of 5.5 years and were followed in the current study at 8 and 10 years of age. At the 8-year follow-up, parents were asked by telephone whether their child had received any treatment or diagnosis since the 5.5-year assessment, as well as to what extent (approximately 25%, 50%, 75%, or 100% of the time) the child still walked on the toes. At the visit when the children were 10 years of age, their parents were asked the same questions. All 26 children also underwent a neurological examination and an orthopaedic examination focusing on the lower extremities.

Results: At 8 years of age, 6 of 26 children had ceased toe-walking, and by the age of 10 years, 50 (79%) of the original 63 patients had spontaneously ceased toe-walking. Idiopathic toe-walking did not result in contractures of the triceps surae. One subgroup of children displayed early contracture of the ankle and should thus not be considered idiopathic toe-walkers. Four of the children who still toe-walked at the age of 10 years demonstrated some neurodevelopmental comorbidity.

Conclusions: By the age of 10 years, 79% of the children who have ever been a toe-walker spontaneously develop a typical gait, without intervention or contractures of the ankle dorsiflexion. The diagnosis of short tendo Achilles should be retained as a separate diagnosis as there is a subset of children with this entity who should be treated early in childhood. Neurodevelopmental comorbidities are common among those who continue to toe-walk.
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NewsBot · Jun 6, 2018

Toe walking after three: how serious could it be?
Ustaris LM et al
BMJ Case Reports [30 May 2018, 2018]

A 4-year-old girl with no significant medical or family history presented with toe walking, leg pain, unsteady gait and frequent falls for 2 months. Examination revealed upper motor neuron signs in the lower extremities. Laboratory tests were normal including creatinephosphokinase and lactate dehydrogenase. Brain and lumbar spine MRI were normal. MRI cervical and thoracic spine showed a large intradural and extradural mass arising from the right C7 nerve root, widening of the neural canal with evidence of cord compression. She underwent C6-C7 laminectomy with excision of the tumour. Pathology revealed spindle cell tumour with extensive expression of S100 protein and CD56, with Ki-67 proliferation index of 1%-2% consistent with benign schwannoma. She made an excellent recovery following surgery and physiotherapy sessions. Review of literature shows rare reported case of schwannoma prior to the third decade of life.
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NewsBot · Jul 18, 2018

The Utility of Normative Foot Floor Angle Data in Assessing Toe-Walking
Albert H.VetteabJoe M.WattbcJustinLewickebBethWatkinsbLee M.BurkholderdJohnAndersenbcGian S.JhangrieSukhdeepDulaibc
The Foot; 11 July 2018

Highlights
•A normative set of foot floor angle data in children during gait was established.
•The utility of normative foot floor angle in assessing toe-walking was studied.
•Foot floor angle was significantly different between toe-walking and norms.
•Foot floor angle was significantly improved following plantarflexor lengthening.
•Floor interaction kinematics derived via ankle dorsiflexion angle can be misleading.
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Initial heel contact is an important attribute of gait, and failure to complete the heel rocker reduces gait stability. One common goal in treating toe-walking is to restore heel strike and prevent or reduce early heel rise. Foot floor angle (FFA) is a measure of toe-walking that is valuable for quantifying foot orientation at initial contact when using ankle dorsiflexion angle alone is misleading. However, no age-standardized FFA norms exist for clinical evaluation. Our objectives were to: (1) obtain normative FFA in typically developing children; and (2) examine its utility in the example of toe-walking secondary to unilateral cerebral palsy. Gait kinematics were acquired and FFA trajectories computed for 80 typically developing children (4-18 years). They were also obtained retrospectively from 11 children with toe-walking secondary to unilateral cerebral palsy (4-10 years), before and after operative intervention, and compared to 40 age-matched, typically developing children. FFA at initial contact was significantly different (P < .001) between pre-surgery toe-walking (−14.7 ± 9.7 degrees; mean ± standard deviation) and typical gait (18.7 ± 2.8 degrees). Following operative lengthening of the gastrocnemius-soleus complex on the affected side, FFA at initial contact (−0.9 ± 5.3 degrees) was significantly improved (P < .001). Furthermore, several cases were identified for which the sole use of ankle dorsiflexion angle to capture toe-walking is misleading. The assessment of FFA is a simple method for providing valuable quantitative information to clinicians regarding foot orientation during gait. The demonstrated limitations of using ankle dorsiflexion angle alone to estimate foot orientation further emphasize the utility of FFA in assessing toe-walking.
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NewsBot · Oct 11, 2018

Identifying methods for quantifying lower limb changes in children with idiopathic toe walking: A systematic review
Antoni Caserta, Prue Morgan, Cylie Williams
Gait and Posture; Article in Press

Highlights
•A range of measurement tools are used in children with idiopathic toe walking.
•Interventional studies are more likely to include ROM and gait analysis.
•The Alvarez classification is the contemporary choice of ITW quantification.
•Outcome measurement consensus would enhance ITW management.
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Background
Idiopathic toe walking (ITW) is a diagnosis of exclusion for children walking on their toes with no medical cause. This systematic review aimed to identify and evaluate the clinical utility, validity and reliability of the outcome measures and tools used to quantify lower limb changes within studies that included children with ITW.

Methods
The following databases were searched from inception until March 2018: Ovid MEDLINE, EBESCO, Embase, CINAHL Plus, PubMed. Inclusion criteria were studies including children with ITW diagnosis, reporting use of measurement tools or methods describing lower limb characteristics, published in peer-reviewed journals, and in English. The relevant psychometric properties of measurement tools were extracted, and assessed for reported reliability and validity. Included articles were assessed for risk of bias using McMaster quality assessment tool. Results were descriptively synthesized and logistic regression used to determine associations between common assessments.

Results
From 3164 retrieved studies, 37 full texts were screened and 27 full texts included. There were 27 different measurement tools described across joint range of motion measurement, gait analysis, electromyography, accelerometer, strength, neurological or radiology assessment. Interventional studies were more likely to report range of motion and gait analysis outcomes, than observational studies. Alvarez classification tool in conjunction with Vicon motion system appeared the contemporary choice for describing ITW gait. There was no significant association between the use of range of motion and gait analysis outcomes and any other outcome tool or assessment in all studies (p > 0.05).There was limited reliability and validity reporting for many outcome measures.

Significance
This review highlighted that a consensus statement should be considered to guide clinicians and researchers in the choice of the most important outcome measures for this population. Having a standard set of measures will enable future treatment trials to collect similar measures thus allowing future systematic reviews to compare results.
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NewsBot · Nov 26, 2018

Full length foot orthoses have an immediate treatment effect and modify gait of children with idiopathic toe walking
JoanneMichalitsis et al
Gait & Posture; 20 November 2018

Highlights
•Foot orthoses and high-top boots reduce the immediate occurrence of toe walking.
•With this treatment children with ITW alter their stance and swing phases.
•Children with ITW increase stride time and double support time with this treatment.
•The longer ground contact time may reflect subtle change in local dynamic stability.
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Background
There remains a substantial lack of evidence to support the use of foot orthoses as a conservative treatment option for idiopathic toe walking (ITW). Encouraging heel contact during gait is one of the primary goals of most interventions in paediatric ITW.

Research Question
Does the combined treatment of high-top boots and orthoses increase the number of heel contacts during gait and change spatio-temporal gait parameters?

Methods
This within subject designed randomised controlled trial recruited fifteen children diagnosed with ITW (n = 10 males). They were fitted with bilateral custom made rigid contoured carbon fibre foot orthoses placed inside high-top boots. To analyze the effect of this treatment, heel contacts and spatio-temporal parameters measured by an 8.3 m Gaitrite® mat were compared to barefoot walking and shod walking.

Results
An immediate increase in heel contact (p = 0.021) was observed in the combined treatment only. Gait changes included a large increase in stride time in the combined treatment condition compared to barefoot walking (p = 0.006). This was associated with a decrease in the percentage of swing phase in the gait cycle (p < 0.010), an increase in stance phase (p < 0.010) and an increase in double support time (p < 0.001).

Significance
These results suggest the hardness and thickness of the shoe and stiffness of the orthosis midsole may lead to improved local dynamic stability and foot position awareness with increased sensory feedback provided through the entire length of the foot. Further research is indicated to validate this treatment option on long term outcomes in this population group.
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