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Juvenille ankle equinus case

Discussion in 'Biomechanics, Sports and Foot orthoses' started by David Smith, Sep 16, 2021.

  1. David Smith

    David Smith Well-Known Member


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    Hi Everyone

    I have a 12 year old boy with ankle equinus complaining of toe walking and discomfort (not pain) in medial GSC - "feels like the muscle is trying to pull out the back of my calf" he says - Ankle equinus = minus 14dgs dorsiflexion - I mobilised to about -3dgs dorsiflexion. (IE 0dgs d/flexion is 90dgs plantarfoot relative to tibia plus(+) is more dorsiflexed and minus is less dorsiflexed than 90dgs)

    When he walks on toes, he takes long strides, I think because this enbales him to get onto heels more easily, tends to use pelvic rotation and hip extensors for propulsion and keeps knees quite extended thru stance. slightly circumducting swing phase. He plays football and running seesm to be more of a normal progression and less of a problem than walking

    No Clonus - Mum denies history of CP and no other signs - no neuro deficits apparent - She reports son has had no growth spurts

    I've started him with 10mm heel lifts and range of motion and stretching exercises - and instruct to reduce stride length and increase cadence in walking - see how things are in a few weeks

    any tips or ideas for this one please?
     
  2. efuller

    efuller MVP

    How long has he been toe walking? If that started recently, I would question how observant mum is on growth spurts. Cavus foot?
     
  3. Bug

    Bug Well-Known Member

    Kid’s don’t just get tight muscles to treatment is often dictated by cause.
    Consider all the causes of toe walking and rule them out or refer to a children health professional is there are red flags like prematurity or special care nursery. Missed CP (GMSCS 1) is very common in kids who toe walk, as it onset of dystrophies. These kids rarely have clonus so good history and good neuro assessment with reflexes and monofilaments.


    Once you are sure of the reason, goal based care and equinus management. Which is really dependent on the reason to the toe walking.

    I’m not sure of some of you rationale for treatment as neither mobs nor isolated heel lifts have any place in toe walking for any causes.

    One you’re settled with causality (or an absence of) then treatment follows that path.
    Parents of kids who toe walking get told a lot of stuff and get sold a lot of woo. I can shoot plenty of guidelines and evidence informed treatments but won’t until you really know the cause.

    ETA: please ring Mum and ask to speak to him and tell him to walking any way he wants right now. Last thing a 12 year old needs is to try and modify their gait. They will fail, feel like a failure and their friends will tell them they are being weird.
     
  4. efuller

    efuller MVP

    David did say mother denied CP and no neuro deficits apparent. What are some non neurological causes of toe walking?

    The kid has pain in his calf that is consistent with the muscles working really hard at keeping the heel of off the ground. It also sounds as if he has an unusual gait. Heel lifts might relieve his pain and make his gait appear more normal. Why do you think that heel lifts have no place in toe walking?
     
  5. Bug

    Bug Well-Known Member

    Neuro causes that require more than history because they can be mild, may have been early onset, or parents don’t know, and rarely do the mild ones have clonus:
    CP, CMT, many types of muscular dystrophy that present around this age in a mild or progressive form where toe walking can be the first sign, tethered cord and the list goes on. There just wasn’t enough info there from history or assessment or history of the toe walking to then move into let’s treat because treatment principles are very different when someone toe walks from a neuro condition.
    Kids who toe walk without neuro stuff may also have DCD, adhd, autism, hypermobility or other conditions where they toe walk as the movement is less complex or gives their some sensory input they require, but it should be a normal muscles that may get tight.

    Orthopaedic conditions you can usually see or they hurt. They are usually assymetical and new unless congenital. Kids who have an equinus talipes are commonly managed from birth.

    Then you’re left with idiopathic toe walking. Which it well may be. At 12, first presentation, commonly rare though as 1 in 20 healthy kids toe walk, at 5. Of these, ~80% get better, the rest need treatment by 10 (engstrom). Having a 12 year old slip through the treatment loop makes me nervous there is something else there and would want either a very good paed or neuro or experienced paed health professionals make the call on ITW. Treatment of toe walking then is most effective when the cause is understood, and rarely effective when only ankle equinus management is the only focus.

    My statement about heel lifts, I don’t understand why you would think they would be? Kids who toe walk rarely get their heels to the ground. Bringing the ground up by 0.6 or 1.0cm is commonly not enough for them to even touch the heel lift. Then what’s the long term plan?
    I get if the principle is to let them feel the floor but then the lift would have to be high enough, but otherwise, heel lifts can decrease the working muscle unit length, increase activity in an already active muscle (Rabusin, 19) and there has been no known protocols testing their use in kids, particularly and prepubescence when they are about to have a massive growth. So I guess if they help him hit the ground, short term and there is lots of wrap around care to increase length, otherwise they will be either useless or a contributor to ongoing tightness. There are much more effective management strategies IF it’s ITW.
     
  6. David:

    Starting this 12-year-old boy on a three-times-per-day gastrocnemius and soleus stretching exercise program would certainly be what I would recommend for this patient on the first visit. In addition, on the first visit I would inspect shoes, and recommend a higher heeled running-style shoe (a 10-12 mm heel drop running shoe versus a zero-drop Vans or Converse pair of flat shoes that are so popular in this age group). Also, on the first visit, I would trial different thicknesses of heel lifts in the shoes to see what thickness of heel lifts would allow him to walk with his heels contacting the ground during walking gait. I wouldn't add more than 1.5-2.0 cm to the shoes. From there, if the symptoms start improving, then the heel-lifts would be gradually reduced in thickness as the gastrocnemius-soleus-Achilles tendon complex is lengthened.

    Likewise, performing a thorough gait examination is critical in toe-walkers at this age. Watch them walk barefoot, watch them walk and run in shoes with no heel lifts, then watch them walk and run with heel lifts to see how they respond. Some toe-walkers will bring their heels down more to the ground even in flat-heeled shoes versus barefoot walking. I assume this odd response is due to some aversion to them having their bare heels hit the ground.

    Many of these children will also have more narrow heels (from medial to lateral) than normal. I believe the narrow heel shape in these individuals is due to the majority of forces acting on the posterior half of the calcaneus during weightbearing activities coming from the overwhelming Achilles tendon tension forces, with very little ground reaction force acting on their plantar heels. I have found it interesting over the years to see that in the adults who have these narrow heels. 9 times out of 10, when I ask these adults if they toe-walked as a child, they said that they did toe-walk, but eventually "grew out of it".

    Over the past 36 years of treating these patients, I have also noted that these children invariably are much better and more fluid at running than they are at walking. Their inability to contact the ground with their heels produces some very strange walking gait patterns. However, once the gastrocnemius-soleus-Achilles tendon complex is stretched out some, and they are placed into running style shoes (with a 10-12 mm heel drop) with another soft heel lift inside the shoe, the walking gait pattern, within four weeks, is nearly always significantly improved. If the gait and/or symptoms have not improved within 4-8 weeks, and you are certain that the child and parents have been following your stretching/shoe/heel lift program, then it may be wise at that time to recommend a neurology consult.

    Hope this helps.
     
  7. David Smith

    David Smith Well-Known Member

    Hello Bug

    Thanks for your very interesting thoughts
    The onset has been recent according to Mum and certainly the symptoms are reported as recent by the boy.
    After you input I went back to basics and read thru 3 papers and articles from multi discipline writes. While they all recognise the various causes of ankle equinus ie various neurological disorders, neuro muscular disorder, soft tissue contractions and osseous impingements, the focus seems to be on 'what can we do with the presentation once we've determined whether the equinus is bony, soft tissue or psuedo. If we move past infant and very young child who may move straight into a surgical intervention, the overall protocol seems to be - conservative first then surgical, there is no mention of directly addressing the neurological disease. The basis of all conservative intervention seems to be as outlined by Kevin Kirby above. Of course there are Neuro physiotherapists specialising in Paediatrics - by my experience they are few and far between and have a very narrow area of specialisation even within there sub speciality. Having spoken to Physiotherapist colleagues there opinion was that the major problem with rehab in this type of case is 'compliance' and without compliance to a rigorous programme there is no chance change toward a good outcome. ?That would apply to any patient to some degree of course but we can only do what we can do and hope that the patient is amenable - this is where our input to enable the patient in their own ability to enter onto their own health care is so important. So, Bug, how would your intervention differ assuming a neurological deficit and what subtle signs would you look for in the absence of overt neuropathological symptomatology?
     
  8. Bug

    Bug Well-Known Member

    Do you mean the onset of toe walking or the onset of symptoms (as in tightness etc).

    If new onset of toe walking, tethered cord is always in the back of my mind with kids who toe walk at any age where there are new symptoms. Monitor patella/ankle reflexes, asking about any chances in sensation in the limbs, particularly in the groin and if there are any changes in day or night continence. There are the key things that rapidly escalate care. Or if new onset of toe walking, at this age, additional subtle signs such as a graded Gowers, monofilament along dermatomes, changes in foot posture over time or simple muscle strength measure that are either functional, like a standing long jump or 2 minute walk test, or more empirical like a dynamometer should also be considered.
    If new onset is symptoms, I'd again consider all the the above but get better toe walking history or when, how long, has it changed etc because if the toe walking is gradually getting worse with time rather than better, it's not always ITW.

    Evidence does not support stretches and it's rare that kids can do them enough to actually make any difference. If the family is keen and want to give a crack, a neurological type sustained stretch often makes a bigger different than static short. So a wedge board with good postural alignment for at least 10 min can make some gains, they are rarely sustained though.

    If there is a neuro deficit, or even child unable to get their heels to the ground and there is discomfort, the most effective treatment is serial casting. It's super difficult in COVID times to initiate this right now so if you have experienced clinicians near you, it would be the treatment of choice with the ROM you have mentioned.
     
  9. David Smith

    David Smith Well-Known Member

    Bug

    I text some questions to the Mum and she now says that her daughter noticed changes in her brothers walking 2 years ago but they couldn't see it - mum noticed some changes many months ago but Son reports calf muscle pulling symptoms more recently 3 - 4 months ish perhaps
     
  10. Bug

    Bug Well-Known Member

    Every country is different. But what you have described would reach the threshold here for me to refer back to GP and request a spinal MRI and brain MRI/CT scan prior to ongoing treatment or referral to neuro or ortho pending results or referral to one of those for the scans. I see referral as a valid form of treatment, not everyone thinks it is though so up to you. Some will think it's overkill. We're all influenced by the cases we see. I see lots of kids who toe walk and lots of cases where the underlying reason is missed and discounted as ITW.
    Good luck going forward.
     
  11. David Smith

    David Smith Well-Known Member

    Good food for thought Bug, thank you
     
  12. David Smith

    David Smith Well-Known Member

    Yes good stuff thanks Kevin, I'll check out heel width as a mater of interest. Your plan along with Bug's is a continuum allowing good time for in depth assessment of presentation, evaluation of initial interventions with a plan to move toward neurological investigation if symptoms persist. Bug, what would your request be for MRi referral, would you be thinking Spina Bifida or Cervical impingement syndrome for instance. What would be the most likely spinal deficit you would expect to see in a juvenile with changes in gait?
     
  13. Bug

    Bug Well-Known Member

    It really is a rare disease but one needing to be considered, most common I see that is early missed and present later in in older kids is tethered cord, but I acknowledge I have a high toe walking case load so what I see in a year, some would see in a life time of practice: https://rarediseases.org/rare-diseases/tethered-cord-syndrome/

    But also this is the age of some dystrophies which a simple blood test could rule in or out.
    Basically, new toe walking means referral. I outline my concerns in the letter to the GP and stress the new symptomatic presentation and let it roll from there. These are never things I encourage to stay with general practice but escalation to pead, neuro or ortho depending bloods and scans.
     
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