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Toe walking

Discussion in 'Pediatrics' started by NewsBot, Jul 18, 2006.

  1. NewsBot

    NewsBot The Admin that posts the news.


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    The neuromuscular demands of toe walking: A forward dynamics simulation analysis.
    J Biomech. 2006 Jul 11;
  2. NewsBot

    NewsBot The Admin that posts the news.

    Linking clinical measurements and kinematic gait patterns of toe-walking using fuzzy decision trees
    Gait and Posture. Published online 13 July 2006.
  3. NewsBot

    NewsBot The Admin that posts the news.

    Comprehensive outcomes of surgically treated idiopathic toe walkers.
    J Pediatr Orthop. 2006 Sep-Oct;26(5):606-11
    McMulkin ML, Baird GO, Caskey PM, Ferguson RL
  4. NewsBot

    NewsBot The Admin that posts the news.

    Idiopathic Toe Walking: A Kinematic and Kinetic Profile.
    Westberry DE, Davids JR, Davis RB, de Morais Filho MC.
    J Pediatr Orthop. 2008 April/May;28(3):352-358.
  5. Admin2

    Admin2 Administrator Staff Member

  6. Bug

    Bug Well-Known Member

    Keep going newsbot. You are helping with my PhD lit review.....here is a few others too:

    Classification of idiopathic toe walking based on gait analysis: development and application of the ITW severity classification.
    Alvarez C, De Vera M, Beauchamp R, Ward V, Black A
    Gait & Posture. 26(3):428-35, 2007 Sep.

    Have a few more if people are interested especially about treatment modalities and their outcomes short and long term.

    Nothing still though on Toe walking and its link with sensory processing.... :(
  7. Boots n all

    Boots n all Well-Known Member

    bug said "Have a few more if people are interested especially about treatment modalities and their outcomes short and long term."

    Very interested please bug, l see a few every month, some referrals and some"Walk in" the referrals come with full length carbon plates already supplied to have fitted to our boots for them, whilst the walk in's are up to me.

    The most extreme case l have currently has given up walking altogether, went from walking main stream style, to toe walking, to now kneeling, walking on their knees with callas build up on the knee, anterial ankle and dorsum of the foot from the constant dragging............ l like a challenge.
  8. Bug

    Bug Well-Known Member

    No problems David - I'll pm you!

    As far as your extreme case, at the risk of sounding all teenager but "Wooooh, man, that is huge!".

    It does though hark back cause and effect. Are you treating the walking/gait style or the effect of equinus.

  9. Boots n all

    Boots n all Well-Known Member

    Through a combination of the ankle boot and Orthosis we are trying to improve gait cycle, hopefully a longer stride and better heel contact and to do that we need to attend to the equinus, its all part and parcel the same.

    Its interesting to watch this child after a four weeks in the Boot and orthosis she is starting to walk more often, with a slightly lower heel height until you introduce another child into the environment, then she goes to her knees again, the fear of been knocked down l guess.

    We also request that they have the child been seen by an Osteopath every 2 weeks, l understand the Osteopath is working the legs and lower torso, l leave that up to them

    Pm received thank you
  10. Bug

    Bug Well-Known Member

    Interesting David.

    Any theories though on what started it all? The children that I am most interested in treating and seeing is those that have either no gastroc soleus tightening or the process has only started.

    As far as your young girl, the fear of where she is in space or the fear of being unbalanced by another child would also have me inclined to send her off to a Occupational therapist. If she is that spatially challenged then there is something more going on there than just tight muscles and odd gait.

  11. David Smith

    David Smith Well-Known Member


    What are full length carbon plates and how do they help resolve or accomodate toe walking. What is the boot and othosis combo that you talk about.

    How do you usually treat idiopathic toe walkers?

    Cheers Dave
    Last edited: Apr 4, 2008
  12. David Smith

    David Smith Well-Known Member

    Without reading the full paper it would seem quite obvious that a toe walker might experience lower ankle moments since they will tend to have a plantarflexed foot then the moment arm available to GRF will be much shorter than normal. The extra muscular activity (besides being less efficient for greater motor unit action potential) will be increasing internal joint forces but not moments.

    Wouldn't that make sense?

    Cheers Dave
  13. Boots n all

    Boots n all Well-Known Member

    The child has had CP ruled out, there is no muscular reason for it at all, she is seeing a Chinese Medical Doctor who does massage, we did have her seeing a Osteopath but the parents thought better, which is cool as they have to be comfortable with their decisions they make.
    As to what started it all, l have no idea and neither do the parents, no other siblings although one is not far away, they seem like a very loving normal family with no real issues that present themselves whilst with me, the sort of client you would be happy to sit and have a coffee with:drinks.

    The full length carbon plates are not supplied by me, they are supplied by Physio and Podiatrist.
    The latest one sent by a pod is asking for a stiff soled ankle boot to accommodate a 6mm carbon plate, how these fix the problem, l am not sure they do if you understand me, they are simply putting the child into a fancy cast, maybe l am wrong, the full length carbon fiber plate does not allow for much movement of the foot all, the child's weight is 19kg, why he needs 6mm l am not sure but l follow the script supplied.
    By the way the child has been in a 3mm full length plate and boot for the last 6 months.

    The boot we would supply, as will be 2 pair picked up today are like this one http://www.bilbyshoes.com/bilby/PageDisplayServlet?PageID=1155
    As for the orthosis if l did it..... it is soft flexible insole that has a number of ridges in different locations working on the work of Lothar Jarling of Proprioceptors, l really hate saying this as you may think me a P***k for this but due to contract l am unable to say too much about it, ...dont ask me why but they are the rules given to me, sorry, but l am told there are others out there that use soft orthosis also.
    Last edited: Apr 4, 2008
  14. Bug

    Bug Well-Known Member

    David, I have used the carbon plates at time as simply a means to change the habit. It makes it physically harder for the child to go up on the toes. There is a pod at Monash Medical Centre (I see you are in Melbourne) that did some research with a biomechanist and a phsyio on the boots and full length orthotics with a strength/stretch program: http://www.monash.edu.au/pubs/monmag/issue11-2003/research/toes.html

    I think they have their place but only after you have excluded everything from diagnosis that you can are are stuck with pure idiopathic toe walking from equinus. From what you are describing and even from what you are instinctually describing for preferred treatment there is more there than just the toe walking even if there was equinus present (which you haven't mentioned there is?)

    It is interesting what you are saying about soft orthosis. I have been chatting to a physio in the practice that uses these: http://www.ptz-pomarino.de/englisch/zhpgengl/treatmentpyramide.htm that is working on similar principle.

    Either way I would keep a good OT up your sleeve for when the Chinese Doctor has run to the end of their treatment and is stuck.
  15. Adrian Misseri

    Adrian Misseri Active Member


    I have also used the carbon fibre plates wil good success in patients, and teh 3 mm seems to suffice, even with adolescent children. Actually I've done with same with 4mm polypropylene plates as well, when I couldn't get hold of carbon fibre plates. Did the same job, happy walkers, happy parents, happy podiatrist. :eek:)

  16. Asher

    Asher Well-Known Member

    Hi all,

    This is a very interesting thread and the link to the researchers at Monash University was appreciated, thanks Bug. It seems eccentirc exercises like Alfredson's is the go more than a standard calf stretch.

    I have not seen a lot of toe-walking, mainly mild habitual cases but a severe case presented a few days ago. The degree is severe but the child is able to walk with a heel-toe gait when asked to.

    I have not used the carbon / poly plates before. I can see that flexing at the MPJs will be more difficult and help to 'break the habit'. I just can't imagine how the kid manages to walk at all. To my way of thinking, they will have to still go up on their toes, or abduct the feet in order to move forward. Do you need to issue a shoe with a rocker sole?

  17. Craig Payne

    Craig Payne Moderator

    Thats just because kids are shorter than adults and want to be taller. The Arena'ettes have started doing it!

    We also had this thread on habitual toe walking
  18. Adrian Misseri

    Adrian Misseri Active Member


    Yes the flexion at MTPJs is significantly reduced, but it works......
    also seems to work when combined with an ankle brace instead of a camm walker for patinet ho need cam walkers but cant use them due to work etc. i.e. welders/builders etc
  19. Boots n all

    Boots n all Well-Known Member

    :D Hehe, l like that response, l might use it.

    That is my concern also, but none of those prescribing the rigid inserts have ever asked for a rocker sole, even when l point it out it seems to get no response.

    If you put the child into a rigid full length insole and no rocker sole for a long period where does this leave the child after 12 months, with an abducted short gait? do they need help with their altered gait cycle because of the cure ?

    Would you personally wear a shoe that had a rock hard insole in it?
    l would think it should be built within the sole at best.
  20. Bug

    Bug Well-Known Member

    I generally find that I don't need to use it for more than 12 months and that the child's gait isn't really affected at all. They aren't wearing the shoe all the time however. I generally put a little kink in mine so there is some rocker.

    At the same time however I am madly scrambling to find what has caused the toe walking to begin with. if short muscles, treat. If sensory issues, treat etc.....

    Adrian - interesting with what you mentioned about the brace, have you ever tried ankle weights? Sometimes has the same effort. Increase the proprioception at the ankle joint and down they come.

    Same with some of the various wedges, increase the pressure through the joints and down they come.

    Fascinating........keep the questions coming. Just the sort of conversation that I need at present about toe walking.

    As an aside....Craig, this toe walking thing and the Arena'ettes, now surely not the Jolly jumper fans. :drinks
  21. Boots n all

    Boots n all Well-Known Member

    l understand what you are saying but the kink you put in the sole, do you think that the kink in the sole will stay and is there a matching kink in the plate ? if not wont they work against each other?

    l always felt that the child didn't step out enough once a stiff ankle boot and plate were applied.

    It is interesting how each child and parent react to the condition.

    A 6 year old girl picked up her boots Saturday, mum warned me that she wanted the most boring looking boot l could do, "nothing girly on it to accommodate the plate"
    The Girls reaction
    "These boots look yuk"
    Mothers response
    " Then walk flat footed and l will buy you the prettiest boots the man can make for you":bang:
    Girls response
    "All right then"

    Will fashion sense win where the carbon plate may not:cool:
  22. Asher

    Asher Well-Known Member

    Thanks Bug, but I don't understand what you mean by little kink. Is this in the sole of the shoe?

  23. Bug

    Bug Well-Known Member

    No, in the plate. I'll heat it up and pop a kink in it. Almost a little rockerbottomish, about 5 degrees at the forefoot. The kids that I often treat have to have these go into their sneakers or any other shoe. It is often a choice between a high top boot or dinner on the table so we really need to work with the foot wear that they have.

    I do agree though that it affects the stride length however some studies have shown that the long term impact of toe walking leading to gastroc soleus equinus and even externally rotated tibial position in older children/adults.

    As far as fashion sense winning. I wish it was all that easy, in my experience though....no. Crossing the fingers for you that it is.
  24. Asher

    Asher Well-Known Member

    Thanks Bug for your advice.

  25. NewsBot

    NewsBot The Admin that posts the news.

    Assessing the feasibility of classifying toe-walking severity in children with cerebral palsy using a sensorized shoe.
    Mancinelli C, Patel S, Deming LC, Schmid M, Patritti BL, Chu JJ, Beckwith J, Greenwald R, Healey J, Bonato P.
    Conf Proc IEEE Eng Med Biol Soc. 2009;2009:5163-6.
  26. NewsBot

    NewsBot The Admin that posts the news.

    Idiopathic toe walking (ITW)--normal or pathological?
    Jóźwiak M, Ławniczak D, Manikowska F, Idzior M.
    Chir Narzadow Ruchu Ortop Pol. 2010 Jan-Feb;75(1):24-9.
  27. NewsBot

    NewsBot The Admin that posts the news.

    Effects of motor control intervention for children with idiopathic toe walking: a 5-case series.
    Clark E, Sweeney JK, Yocum A, McCoy SW.
    Pediatr Phys Ther. 2010 Winter;22(4):417-26.
  28. NewsBot

    NewsBot The Admin that posts the news.

    Idiopathic toe-walking in children, adolescents and young adults: a matter of local or generalised stiffness?
    Raoul Engelbert, Jan Willem Gorter, Cuno Uiterwaal, Elise van de Putte and Paul Helders
    BMC Musculoskelet Disord. 2011; 12: 61.

  29. NewsBot

    NewsBot The Admin that posts the news.

    Automated method to distinguish toe walking strides from normal strides in the gait of idiopathic toe walking children from heel accelerometry data.
    Pendharkar G, Percival P, Morgan D, Lai D.
    Gait Posture. 2012 Jan 31.
  30. NewsBot

    NewsBot The Admin that posts the news.

  31. Boots n all

    Boots n all Well-Known Member

    "......The testing sequence was randomized to attain 10 trials per surface"

    It doesnt state the size of "Gravel" but 10 trials on gravel for children with a mean age of 6.7 years - Ethics?
  32. Bug

    Bug Well-Known Member

    I wish they would publish it so we can can know and consider it more. I know it's tough but.....
  33. Boots n all

    Boots n all Well-Known Member

    Great talk today at IPS 14, thank you Cylie!
  34. Bug

    Bug Well-Known Member

    Many thanks again for the invitation Dave, happy to be part and hope it continues to make people think about how we work with these kids and their families.
  35. Boots n all

    Boots n all Well-Known Member

    Cylie l was going over my notes from the symposium last weekend

    Do you think that their response to low level vibration would open the door to the idea of a vibrating insole for this client base?
  36. Bug

    Bug Well-Known Member

    I don't know Dave but I think there is warrant in looking at it. Problem with vibrating insoles is that it is a localised effect and the low level I suspect would be too low.

    I don't know if the kids I have seen and using whole body vibration if there is a gait change as we haven't formally analysed it yet. I have seen though an immediate short time change in ankle equinus. We are using 50 hz and this is enough to feel it in your jaw so I suspect you can't make an insole do that.

    Stay tuned.
  37. Cylie: I have a question for you as our resident expert on toe walking.

    Are there any long-term studies that show that toe walking children have greater rates of foot and lower extremity injuries/pathologies as adults than do non-toe walking children?

    If toe walking children don't have any increase in adult injury/pathology rate, why not just observe them all over time, instead of worrying about coming up with ways to treat them. From my clinical experience, nearly all of them become non-toe walkers as adults with no pathologies?

    Since you treat many more of these children than I do, and did your PhD on this subject, I would be interested in your great knowledge and clinical experience in answering this question for me, and all of those following along.
  38. Bug

    Bug Well-Known Member

    Hi Kevin,

    There currently are no long term studies looking at long term outcomes and you are right, due to that it does complicate things. Longitudinal research is incredibly costly and hard to do however we have recently received ethics approval to initiate an ITW registry and hopefully in the future we can actually find out some of this. In the mean time, I have a small paper coming out soon that many children while still toe walking, report a decrease in quality of life particularly relating to physicality. Many are reporting calf pain as older children/teenagers.

    I've also noted a change in foot shape in the older kid, having a wider forefoot and under developed calc. I'm not sure what this means down the track though. Due to the number of kids coming through, I often also end up seeing the parents who want things fixed as they were toe walkers with no treatment and have ongoing chronic pain. While I understand this is quite different to what you have observed, I think it really may be about numbers of patients coming through weekly. I have plenty of parents who used to toe walking with no ongoing complaints but I have many more that outnumber these with ongoing complaints. While they possibly could have these issues anyway, I find the past toe walking parents have a similar foot type and increased calf, hamstring and LBP, retracted digits and increased callosities at the forefoot. Much of which is past the point of ever getting them to stretch it out or the provision of a cushion device.

    I'm quite pragmatic in my approach after seeing so many and I really don't treat them all. The kids who aren't tight we monitor and leave. Much of the paed neuro research is focused on ensuring adequate length and strength of muscles while the child is growing to reduce the impact on bone modelling, especially prior to to hitting the rapid grow during teenage years. Therefore this is what many of the ITW treatments are based on and I think this is a very important fact to consider.

    So I don't think every child should have treatment however I don't think every child should be dismissed. All should have careful assessment as I think it is really the "TRUE" ITW children that have minimal problems. I would go as far to say that I think the ones that go on to have problems actually have some incredibly mild CP or sit on the spectrum however no tests are subtle enough, and this is really what is the challenge in the long term however that is a debate for another day.

    Sorry for the ramble….I tend to go on.
  39. Thanks for the explanation. Nicely done, Cylie!:drinks
  40. NewsBot

    NewsBot The Admin that posts the news.

    Treatment for idiopathic toe walking: A systematic review of the literature.
    van Kuijk AA, Kosters R, Vugts M, Geurts AC
    Journal of Rehabilitation Medicine [2014]

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