Toe walkers

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Any ideas on braces for children who toe walk?

I have tried a few braces, such as a DAFO as well as just a dropfoot brace.
However, it is tough for children to stay in them and harder for them to do well during the day, especially when they are playing with other children.

I have a couple patients, one 4 yrs and one 6 yrs old who are toe walkers. They are currently undergoing physical therapy to strengthen their anterior leg muscles as well as to stretch their Achilles tendons.

Have you had good results with either special physical therapy and or specific braces?

Thank You.

Sharyn

 

Hi Sharyn,

Have you determined what is causing the toe walking to start with? This greatly impacts your treatment. At 4, if they are that tight you might want to consider neurological testing?

There is conflicting effective treatment regime in literature but it generally goes through the path of:

Strengthen and stretch
Wedges, stiff soled shoes, full length plates in the shoes or orthotics
Serial casting
Boxtox
Surgery

There is no research that I have seen on the use of DAFO's and at the moment I am up to my chin in toe walking literature.

Good luck.
Cylie

 

Hey Bug.

I think there are a few ommissions to your list.

Firstly, why DAFO's? whats wrong with AFO's?

I would only use a Dafo i i specifically wanted to get extension in the knee.

AFO's, however, i use with great effect.

Also night splints is something i would throw in before resorting to serial casting.

I would agree that the first question is why the child is toe walking. Is it structural or functional? If functional, why?

Regards
Robert

 

Hi There.

Thank You for your responses.
My patient has no neurological disease. She has been to a neurologist just as an added check.
And she has normal range of motion when I examined her, using the Silverskiold Test. And believe it or not, but she does walk plantargrade when I ask her to.

But she prefers to walk on her toes.
I have referred her to a physical therapist, "Kids Therapy Center" where they deal with such kids regularly. The PT also says that our patient walks plantargrade while in the center. However, when she goes home, her parents notice that she walks on her toes.

The only good that has come of all of this it seems, is that she is now aware of her toe walking.

I saw a patient's blog online who had good results using a DAFO. However, I agree with Robert that an AFO would do just as well.

I will next try and AFO as well as a night splint as suggested.
Thank You. Will keep you posted on the results.

Sharon

 

I would leave her alone. A lot of kids just choose to walk on their toes as they want to be taller. If she can walk plantigrade and has no pathology, then no treatment is needed.

 

Hi Craig!

Haha! I thought of that too! That's pretty funny!

I think you are right. The parents want more, so I will try that AFO. If this does not work, I think I will take your advice!

THANKS!

Sharon

 

Robert, I was going on the research that is out there for treatment of toe walking.

Based on that - you do get the leave it alone approach being advocated for. There is no published research on DAFO's or AFO's, and that they are of use for this. There is also nothing on night splints. Well, nothing that I have seen anyway, would love to be proven wrong though. From the kids that I have seen they work well for some, but then so does Bobath therapy, vestibular stimulation, Sensory integration, shoes with flashy lights at heel contact, taping the calf and forefoot etc etc. There is a lot of things we do that might work for some kids and not for others.

That being said...Craig, where's your proof of that they want to be taller? From what I have seen it is just a developmental stage that they go through and some get caught up in that moment. Something about the central pattern generator developing the ability to toe off. They generally have a family history of it, so do they all have a hiccup in this pattern generation? Are they walking from an anterior compartment weakness making the gait more efficient. Is there is a tonal difference?

There are a few long term studies though that show that toe walking long term, only causes a slightly external gait. It is even questionable as to if they have residual equinus.

Which brings us back to the question, what is causing the toe walking? Are you treating the gait abnormality or are you treating equinus.

Then we get to that age old question, what is equinus? How do we know how much ankle ROM that child needs for gait.

So many questions and things to ponder for a monday morning....:wacko:

 

..becasue they are shorter ... and how many adult toe walkers are there?

We do nor even know what the normal is for adults ...we used to think it was 10 degrees (life was simpler then).

 

You need one of the orthotics that I have invented (I want to be famous for something) - its called the PCD ... the parental control device :dizzy:

 

Yes, well..... try telling that to my 5"9' toe walking collegue. I'm not sure she will agree that she wants to be any taller, there are still plenty of adult toe walkers out there. Give me a new theory for that one

Human body weight has to come into it though, in regards to it's resolution. It is simply harder to maintain that stance the older you are. Or how many people we see with chronic achilles tendonitiis do we question if they were toe walkers? How many people we see with an early heel lift do we ask if they were toe walkers?

Would love to see your PCD though - do share!

 

Where can I get one???????
:drinks

 

That's definitely older ages to be working with- usually I see them in the clinic around 18 months- 2 years old. Have they toe walked this entire time or just recently? The mean age of toe walking is actually 11 months according to the literature. Interestingly enough, research has shown that toe walkers have increased risk for delays in these categories: 33% have fine motor delays, 40% have visuomotor delays, 27% have gross motor delays, and 77% have speech/ language delays. Toe walking in children 5 and older is usually associated with neurological immaturity.

I actually use a hinged AFO with a plantarflexion block(or DAFO- I'm partial to the Cascade DAFO braces for toe walkers only because they are so flexible and still support where I need them to) for motor learning to occur. The patient typically takes 3-6 months of wearing this brace before they begin walking with flat-foot contact.

Therapy techniques are usually active stretches (since PF are 6 times stronger than DF- I hate passive stretches unless the child is unable to be "tricked" into stretching themselves using their body weight), possible night splints if there is a contracture, AFO's, kinesiotape to facilitate ankle dorsiflexion (can be worn 3-5 days), electrical stimulation of ankle DF (if old enough), and home exercise program for parents.

On a side note, in the case of vestibular or other sensory integration problem, Cascade makes a shoe insert that gives feedback on the foot. It has been proven to reduce toe walking because they don't have to externally deviate the gait pattern to receive this sensory input. Walk on your toe for a whole day (yeah I know you will be sore)....you wouldn't believe the sensory input it provides! :dizzy:

Hope this helps from a different perspective on idiopathic toe walking!

 

Dawn, can you share the reference that proves the cascade device works?

Also - walking on the toes at 11 months is actually a normal gait pattern development in the literature. Apart from neurological/neuromuscular conditions why would you treat prior to 3 as reference in the literature?

I agree with those studies that have shown those delays however their methodology was flawed and the study that proved those risk of delays also used subjects that had high prenatal exposure to drugs therefore increasing the risk of those delays anyway.

It is so complex isn't it.

 

I've heard of the Cascade DAFO from other Doctors and Patients alike.
I was going to give the Wheaton AFO a try, but I will look into the Cascade DAFO. I've been hearing the same product over and over again.

Thank You

 

I have to agree with Craig, no pathology, no Rx.
I do sometimes take a shoe, and get it fitted with a full through carbon fibre stiffener, to make it difficult for the kiddies to toe-walk, and in many cases the parents bring in their shoes and get them adapted but don't tell their kids.

I personally wouldn't be throwing to much treatment at this child. I have found that the pushy parents are the first to complain if a treatment has been initiated that was later considered unnecessary, and think of the delicate state of mind these children at tender ages have.

My nearly 3 year old daughter occasionally toe-walks on a cold tiled floor, and she aint getting any Rx, no way.

 

Bug:

In my 25 years of practice, I don't remember seeing a single adult toe-walker. You say there are "plenty of adult toe walkers". Do you have any references as to show how many adults walk on their toes? From my clinical experience and literature reviews, it seems that the amount of adult toe walkers is so small compared to the amount of child toe walkers, that we can say that nearly all children toe walkers grow out of the problem.

I agree with Peter. Tell the parents to relax, tell the parents that their child's heels will come down with time and to have their child do regular calf muscle stretching exercises, if there is tightness in the calf muscles. And that if the parents are really worried, put the child into a stiff soled shoe that does not allow dorsiflexion of the metatarsophalangeal joints.

 

KK writes
"In my 25 years of practice, I don't remember seeing a single adult toe-walker."

Is that because they got treatment as a child?

l have had a lady here recently 54 years old that toe walks l cant say she is a client just yet, l admit it is the first one l have ever seen, whilst my friend in Sydney had one she is not any more due to treatment that was a 35 years old.

IF the treatment was not there, there may well be lots of Adult toe walkers out there who is to say one way or the other, but l will agree with you they are few and far between... that is because we know how to help resolve the issue

 

Kevin, I do agree there are not near as many adults at children. The literature supports that as well.

This study showed that even after 13 years most of the children regardless of treatment toe walked.
Idiopathic toe-walking: does treatment alter the natural history?.
Eastwood DM, Menelaus MB, Dickens DR, Broughton NS, Cole WG
Journal of Pediatric Orthopaedics, Part B. 9(1):47-9, 2000 Jan.

This one showed about 20% continue though has a very small sample size of 14.
The natural history of idiopathic toe-walking: a long-term follow-up of fourteen conservatively treated children.
Hirsch G, Wagner B
Acta Paediatrica. 93(2):196-9, 2004 Feb.

However if the incidence of children toe walking is about 6% of the paed population as some authors say, then we will still have some. I do agree with David, I often chat to the parents of the toe walkers that I see and they generally say they had treatment of some sort and now rarely toe walk.

I work closely with adult toe walker. The poor thing is constantly subjected to my questioning about it and is a living example of how sensory input impacts toe walking, my PhD question. I have about 4 that I have met in the last 2 years, all of which I have met while treating their toe walking children. Most of them mainly walk on their toes while barefoot rather than when in shoes. In shoes they mainly exhibit early heel lift. The ones I have seen also are quite low on their toes doe to the strength it requires. They ones I have seen are also very good at normalising their gait.

I dare say you will have had one, they were just tricking you.

 

The development of a gait pattern has been researched over many years to determine what is the “norm”. All studies that I have read report there is a relatively short period of time for the maturation of gait. There should be a consistent heel strike by 18 months of age. (Sutherland DH et al. The development of mature gait. J Bone Joint Surg Am. 1980; 62: 336-353) I have seen “toe walking” infants using their stepping strategy with the limbs in an extension synergy (hip & knee ext, ankle PF), which indicates a more reflexive pattern. Research has discovered 3 patterns of gait throughout a lifespan: early infancy pattern, mature pattern, and mature locomotion as related to age. Maintenance of equilibrium is crucial for early walking and since the vestibular system functions from birth, this may contribute to the early coactivation pattern and later the conversion to the sequencing of the anterior tibialis and gastrocnemius in the gait cycle.

As far the reference to bracing, there have not been specific research studies targeting only idiopathic toe walking and the use of AFO’s. The only studies I have seen in regards to ITW were related to botox injections and serial casting. Both have been proven to be beneficial to this population. I have seen both AFO’s & serial casting done on patients for external cueing on heel-toe gait pattern. Both looked great at first, but the difference was when the device was removed. The serial casting (with the walking boot) went right back to a constant toe walking pattern after 6 months. The AFO actually carried over into a more mature gait pattern. Here are the 2 references I could find on short notice regarding DAFO’s:
Dilger N. (2005) Idiopathic toe walking: a diagnosis of exclusion or a developmental marker? APTA Orthopaedic Interventions for Pediatric Patients: The Evidence for Effectiveness.
Farber D. Neuromuscular disorders of the foot and ankle. Current Opinion in Orthopaedics. 2001; 12: 120-124.

Regarding the developmental delays associated with ITW, here is a good article.
Shulman L. et al. Developmental implications of idiopathic toe walking. The Journal of Pediatrics. 1997; 130(4): 541-546. Also Accardo et al. Toe walking and language development. Clinical Pediatrics. 1992; 31: 158-160.

Also a child that occasionally walks on cold tile floor and toe walks would be considered normal in my opinion. It is when you consistently see the toe walking gait pattern that I get concerned.

I consciously (and subconsciously) watch the way people stand or move. I know there are adults who walk on their tiptoes. I have personally experienced that to walk in high heels, you walk with the same pattern as an ITW. Maybe our adults are “self-medicating” themselves with their shoe wear? Maybe there isn’t as many because their “immature” pattern became mature or they consciously began to suppress it?

 

Thanks Dawn, however there is I still have issues with treating a child as young as 18 months for toe walking and am interested in the literature that shows the mean age to be 11 months.

As to heel:toe gait, holding Sutherland et al in isolation I feel, can lead us to treat a gait pattern that is a normal part of development. However even they reiterate that the variability in heel-toe gait patterns means we can't truly say the child will hold a mature gait until they are 3.

Burnett, C. N., & Johnson, E. W. (1971). Development of gait in childhood. II. Developmental Medicine & Child Neurology, 13(2), 207-215.
Holt, K. G., Saltzman, E., Ho, C.-L., & Ulrich, B. D. (2007). Scaling of dynamics in the earliest stages of walking. Physical Therapy, 87(11), 1458-1467.
Ivanenko, Y. P., Dominici, N., & Lacquaniti, F. (2007). Development of independent walking in toddlers. Exercise & Sport Sciences Reviews, 35(2), 67-73.

All support this. Due to this I firmly believe that toe walking in the absence of a diagnosis should not be treated and we are doing our patients a diservice by treating something that most likely will naturally disappear.

Thanks for those AFO references though - that Dilger one is proving hard to find. I take it is was a conference presentation?

The Shulman one you mention is actually the one with the high incidence prenatal exposure to drug use(Heroin, crack, alcohol etc in 8 of the 13 children) therefore their finding were flawed and their linkage between toe walking and delay questionable. However thank goodness Accardo and his mates did more study.

I know what you mean about watching people walking. It's a PITA isn't it! Nothing worse than seeing something you know you could fix in a shopping centre, especially a child!

 

Hi, our local tennis coach and A grade player is a toe walker. He states that he always has been. He is in his 30's. When standing his heel is briefly w/bearing but I notice he is rarely still even when just chatting to parents.
Several years ago he did the OT's and heel raises etc but did not continue saying none of it helped with any symptoms.
he admits that he is very sore when he first gets out of bed in the morning along the heel and arch.

This info has been recieved in between tennis strokes and he has not pursued any Tx, but suggests he should and will one day? not sure that I am looking forward to that day.?

Cheers

 

Unfortunately there is another PCD out there...Could be a good father/husband controlling device!!!

 

I finally figured out where you were getting the 11 months thing…I meant to type that the mean age of walking for those who ended up being toe walkers was 11.14 months. I thought it was worth mentioning because it showed there wasn’t a gross motor delay for those who toe walked. (Sobel E, et al. Effect of toe walking on ankle equinus. J Am Podiatr Med Assoc. 1997; 87: 17-22).

My preferred age for treatment is 18- 24 months old. I like to treat that early because I prefer to be proactive and preventative with my therapy sessions. I begin with 1-2 times per week for usually a month (if severe contracture already and other gross motor delays) then decrease to 1 time per 1-3 months to monitor progress, gait pattern, and milestones before discharge.

If a child who consistently toe walks from 11 months to 3 years of age without receiving any treatment would have multiple consequences from that gait pattern. They would have a contracture of the gastroc/soleus complex (with possible shortened tendon) and weak anterior tibialis. Typically even the quadriceps muscle would be affected because most children who toe walk do so with slight knee flexion, so they would lack strength in terminal knee extension. I have noted that all of my children I have worked with also stand with ankles in a plantarflexed position, which means they are never going down on their heels. I even had a child stand on the dorsum of his feet with toe flexion at 20 months of age, which really had me concerned! One flaw in my experience is that I don’t see a child for therapy unless a doctor orders it, so maybe I am not getting those children who don’t have contractures, delays, possible sensory dysfunction, or other issues that a doctor flags for therapy.

Can I have the reference for the flawed Shulman study? I am very disappointed!
Also, the Dilger reference was a study course, and I would be glad to share if someone can tell me how!

 

Thanks DawnPT, I totally get where you are coming from. It is one of those things that isn't always represented by the literature or the literature doesn't support it. It is a hard clinical judgement to make.


The Shulman study is the one you referenced:
Shulman, L. H., Sala, D. A., Chu, M. L. Y., McCaul, P. R., & Sandler, B. J. (1997). Developmental implications of idiopathic toe walking. The Journal of Pediatrics, 130(4), 541-546.
However with the flawed hypothesis, I still believe it is an important one as at the same time we don't know why children with developmental delay toe walk, we are supposing, because it is an easier and more efficient way.
Are you able to scan the Dilger reference in? If so let me know and I'll message you my email address.

 

Heather and Colleagues:

I consider an adult toe-walker to be one where the heel does not contact the ground during normal walking speeds while barefoot. Does this "tennis coach" actually walk like this when you examine him? From my experience, I would tend to doubt it. If he does toe walk, then it would be nice if you could post a video for all of us to see since it is so rare in an athlete. I find it difficult to recommend any rigorous treatment for any children that are toe walkers since I don't remember the last adult I examined that toe walked barefoot (i.e. no heel contact during barefoot walking).

What exactly is the definition you are all using to define a toe walker? Is it no heel contact during barefoot walking or some heel contact during barefoot walking or no heel contact in shoes......?

 

Hi Kevin,
That is the definition that I am using. During general walking, in or out of shoes, no heel contact.

 

Hi Kevin, I sat and watched this coach for 1/2 hour last night, he has no heel contact as he walks/runs around the children he is coaching.
This is with shoes and I have not treated him as such, but have had some discussions through the wire fence.
He states that he has always done this since childhood.
When standing he does very briefly have heel contact but he is rarely still and is back on the toes and does not stay still for more than a moment.
I have watched him with interest for at least 3 years now
so definitely not in my imagination.
As he is not a client I have not completed assessments of any sort.
Perhaps next term I will request his permission to take some footage. I sponsor the club so that might help.
Tennis has finished for at least a month.

Cheers