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Toe walking is a gait deviation with multiple etiologies and often associated with premature and prolonged ankle plantar flexor electromyographic activity. The goal of this study was to use a detailed musculoskeletal model and forward dynamical simulations that emulate able-bodied toe and heel-toe walking to understand why, despite an increase in muscle activity in the ankle plantar flexors during toe walking, the internal ankle joint moment decreases relative to heel-toe walking. The simulations were analyzed to assess the force generating capacity of the plantar flexors by examining each muscle's contractile state (i.e., the muscle fiber length, velocity and activation). Consistent with experimental measurements, the simulation data showed that despite a 122% increase in soleus muscle activity and a 76% increase in gastrocnemius activity, the peak internal ankle moment in late stance decreased. The decrease was attributed to non-optimal contractile conditions for the plantar flexors (primarily the force-length relationship) that reduced their ability to generate force. As a result, greater muscle activity is needed during toe walking to produce a given muscle force level. In addition, toe walking requires greater sustained plantar flexor force and moment generation during stance. Thus, even though toe walking requires lower peak plantar flexor forces that might suggest a compensatory advantage for those with plantar flexor weakness, greater neuromuscular demand is placed on those muscles. Therefore, medical decisions concerning whether to reduce equinus should consider not only the impact on the ankle moment, but also the expected change to the plantar flexor's force generating capacity
Toe-walking is one of the most prevalent gait deviations and has been linked to many diseases. Three major ankle kinematic patterns have been identified in toe-walkers, but the relationships between the causes of toe-walking and these patterns remain unknown. This study aims to identify these relationships. Clearly, such knowledge would increase our understanding of this gait deviation, and could help clinicians plan treatment. The large quantity of data provided by gait analysis often makes interpretation a difficult task. Artificial intelligence techniques were used in this study to facilitate interpretation as well as to decrease subjective interpretation. Of the 716 limbs evaluated, 240 showed signs of toe-walking and met inclusion criteria. The ankle kinematic pattern of the evaluated limbs during gait was assigned to one of three toe-walking pattern groups to build the training data set. Toe-walker clinical measurements (range of movement, muscle spasticity and muscle strength) were coded in fuzzy modalities, and fuzzy decision trees were induced to create intelligible rules allowing toe-walkers to be assigned to one of the three groups. A stratified 10-fold cross validation situated the classification accuracy at 81%. Twelve rules depicting the causes of toe-walking were selected, discussed and characterized using kinematic, kinetic and EMG charts. This study proposes an original approach to linking the possible causes of toe-walking with gait patterns.
The treatment of idiopathic toe walking in children can include surgical lengthening of the gastrocnemius/soleus complex after conservative options have been ineffective. Previous outcome reports of surgery for idiopathic toe walkers have largely been limited to assessing the sagittal plane motion of dorsiflexion/plantar flexion with minimal quantitative preoperative and postoperative analysis. The purpose of this study was to comprehensively assess the outcome of idiopathic toe walkers that had been treated surgically. Fourteen children seen in our motion analysis laboratory that underwent gastrocnemius or tendo-Achilles lengthening for idiopathic toe walking were retrospectively reviewed. Preoperatively, this group had significantly greater anterior pelvic tilt than normal, decreased peak knee flexion in swing, greater external foot progression, and the expected increased plantar flexion (P < 0.01). Postoperatively, anterior pelvic tilt decreased by a mean of about 4 degrees (P < 0.01), only for the group that had tendo-Achilles lengthening because the gastrocnemius group was close to normal preoperatively, and peak knee flexion normalized. The foot progression angle of this group did not change from preoperative values and remained significantly more external than normal, although dorsiflexion in stance significantly improved after surgery (indicating the goal of the surgery was achieved). Increased external foot progression in idiopathic toe walkers is apparently due to increased external tibial torsion and/or external hip rotation but was unaffected by gastrocnemius/soleus surgical lengthening. Significant improvement occurred on an overall index of gait variables, indicating surgery can be an effective treatment of idiopathic toe walkers.
PURPOSE:: The differential diagnosis in children who walk on their toes includes mild spastic diplegia and idiopathic toe walking (ITW). A diagnosis of ITW is often one of exclusion. To better characterize the diagnosis of ITW, quantitative gait analysis was utilized in a series of patients with an established diagnosis of ITW. STUDY DESIGN:: Patients with an established diagnosis of ITW were analyzed by quantitative gait analysis. Data were recorded as each subject walked in a self-selected toe-walking pattern. The subject was then asked to ambulate making every effort to walk in a normal heel-toe reciprocating fashion. Data were collected to determine if this group of idiopathic toe walkers was able to normalize their gait. Datasets were compared with each other and with historical normal controls.
RESULTS:: Fifty-one neurologically normal children (102 extremities) with ITW were studied in the Motion Analysis Laboratory at a mean age of 9.3 years. In the self-selected trials, significant deviations in both kinematics and kinetics at the level of the ankle were identified. Disruption of all 3 ankle rockers and a plantar flexion bias of the ankle throughout the gait cycle were most commonly seen. When asked to attempt a normal heel-toe gait, 17% of the children were able to normalize both stance and swing variables. In addition, 70% were able to normalize some but not all of the stance and swing variables.
CONCLUSION:: Quantitative gait analysis is an effective tool for differentiating mild cerebral palsy from ITW. Kinematic and kinetic distinctions between the diagnoses are evident at the knee and ankle. The ability to normalize on demand at least some of the kinematic and kinetic variables associated with toe walking is seen in most children with ITW.
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.
diopathic toe walking (ITW), considered abnormal after the age of 3 years, is a common complaint seen by medical professionals, especially orthopaedic surgeons and physiotherapists. A classification for idiopathic toe walking would be helpful to better understand the condition, delineate true idiopathic toe walkers from patients with other conditions, and allow for assignment of a severity gradation, thereby directing management of ITW. The purpose of this study was to describe idiopathic toe walking and develop a toe walking classification scheme in a large sample of children. Three primary criteria, presence of a first ankle rocker, presence of an early third ankle rocker, and predominant early ankle moment, were used to classify idiopathic toe walking into three severity groups: Type 1 mild; Type 2 moderate; and Type 3 severe. Supporting data, based on ankle range of motion, sagittal joint powers, knee kinematics, and EMG data were also analyzed. Prospectively collected gait analysis data of 133 children (266 feet) with idiopathic toe walking were analyzed. Subjects' age range was from 4.19 to 15.96 years with a mean age of 8.80 years. Pooling right and left foot data, 40 feet were classified as Type 1, 129 were classified as Type 2, and 90 were classified as Type 3. Seven feet were unclassifiable. Statistical analysis of continuous variables comprising the primary criteria showed that the toe walking severity classification was able to differentiate between three levels of toe walking severity. This classification allowed for the quantitative description of the idiopathic toe walking pattern as well as the delineation of three distinct types of ITW patients (mild, moderate, and severe).
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.... :(
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.
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
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.
Toe walking is a gait deviation with multiple etiologies and often associated with premature and prolonged ankle plantar flexor electromyographic activity. The goal of this study was to use a detailed musculoskeletal model and forward dynamical simulations that emulate able-bodied toe and heel-toe walking to understand why, despite an increase in muscle activity in the ankle plantar flexors during toe walking, the internal ankle joint moment decreases relative to heel-toe walking.
The simulations were analyzed to assess the force generating capacity of the plantar flexors by examining each muscle's contractile state (i.e., the muscle fiber length, velocity and activation). Consistent with experimental measurements, the simulation data showed that despite a 122% increase in soleus muscle activity and a 76% increase in gastrocnemius activity, the peak internal ankle moment in late stance decreased. The decrease was attributed to non-optimal contractile conditions for the plantar flexors (primarily the force-length relationship) that reduced their ability to generate force. As a result, greater muscle activity is needed during toe walking to produce a given muscle force level. In addition, toe walking requires greater sustained plantar flexor force and moment generation during stance. Thus, even though toe walking requires lower peak plantar flexor forces that might suggest a compensatory advantage for those with plantar flexor weakness, greater neuromuscular demand is placed on those muscles. Therefore, medical decisions concerning whether to reduce equinus should consider not only the impact on the ankle moment, but also the expected change to the plantar flexor's force generating capacity
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.
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.
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/Page...et?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.
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...arch/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?)
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. )
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?
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
Thats just because kids are shorter than adults and want to be taller.
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.
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.
The Following User Says Thank You to Bug For This Useful Post:
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
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"
" Then walk flat footed and l will buy you the prettiest boots the man can make for you"
"All right then"
Will fashion sense win where the carbon plate may not
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.
Thanks Bug, but I don't understand what you mean by little kink. Is this in the sole of the shoe?
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.
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.
The clinical management of children with cerebral palsy (CP) relies on monitoring changes in the severity of gait abnormalities and on planning appropriate clinical interventions. Currently available technology does not make it possible to perform clinical gait evaluations as often as it would be desirable from a clinical standpoint. The use of wearable technology (e.g. a sensorized shoe) could provide an effective means to monitor changes in the severity of gait abnormalities in children with CP. In this paper, we studied a group of children with CP who showed an equinus (i.e. toe-walking) gait pattern, a gait abnormality often observed in children with CP. The aim of the study was to determine the feasibility of relying upon a sensorized shoe to assess changes in the severity of toe-walking. We demonstrated that it is possible to use features extracted from the center of pressure trajectory and ankle kinematics to predict the severity of toe-walking. Our results motivate the development and clinical testing of a sensorized shoe to assess changes in gait patterns that accompany the development, and the response to clinical interventions, of children with CP.
Idiopathic toe walking ITW appears to be a clinical problem in otherwise healthy children after 3 years of age. The definitions includes patients walking on toes permanently and temporally. Goal. definition of kinematical and kinetic determinants of ITW and the use of gait analysis determinants of ITW according to Alvarez.
Material and methods. 8 patients, mean age 7 (4-11), were assessed in Motion Analysis Laboratory with clinical examination use of Vicon 460 (Vicon U.K.) and force plates AMTI (Newton USA). Presence of 1st rocker, early 3rd rocker, and predominance of first ankle dorsal flexion moment was assessed.
RESULTS: 1st rocker was observed in 2 patients--group I, early 3rd rocker in 2 patients group II, and predominance of ankle flexion moment in 3 patients--group III, 1 patient was not classified due to presence of 1st rocker combined with predominance of dorsal flexion moment.
CONCLUSION: thanks to motion analysis we have a tool to differentiate between behavioral and fixed deformities and adjust treatment--physiotherapy, BTX, serial casting or surgical orthopaedic treatment.
PURPOSE: To describe and evaluate the effects of motor control intervention in young children diagnosed with idiopathic toe walking.
METHODS: Five children received motor control intervention in a multiple-case series design using a nonconcurrent, variable baseline. Multiple gait measures were taken before and during the intervention phase. Pre- and posttreatment measures of gross motor development and ankle dorsiflexion range of motion were compared.
RESULTS: During the intervention phase, heel strike frequency showed an upward slope for 1 participant, slight upward trends for 3 participants, and no change for 1 participant. Parents indicated minimal gait change within the children's regular environments. Gross motor skill scores increased but were not statistically significant. Passive ankle range of motion improved and was maintained (P = .002).
CONCLUSIONS: Presentation of children with idiopathic toe walking varies and refinement is needed for gait measures and assessment methods. Intervention improved ankle mobility, but additional components appear necessary to attain spontaneous heel-toe gait.
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.
Idiopathic Toe Walking (ITW) is present in children older than 3 years of age still walking on their toes without signs of neurological, orthopaedic or psychiatric diseases. ITW has been estimated to occur in 7% to 24% of the childhood population. To study associations between Idiopathic Toe Walking (ITW) and decrease in range of joint motion of the ankle joint. To study associations between ITW (with stiff ankles) and stiffness in other joints, muscle strength and bone density.
In a cross-sectional study, 362 healthy children, adolescents and young adults (mean age (sd): 14.2 (3.9) years) participated. Range of joint motion (ROM), muscle strength, anthropometrics sport activities and bone density were measured.
A prevalence of 12% of ITW was found. Nine percent had ITW and severely restricted ROM of the ankle joint. Children with ITW had three times higher chance of severe ROM restriction of the ankle joint. Participants with ITW and stiff ankle joints had a decreased ROM in other joints, whereas bone density and muscle strength were comparable.
ITW and a decrease in ankle joint ROM might be due to local stiffness. Differential etiological diagnosis should be considered.
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.
Toe walking mainly occurs in children due to medical condition or physical injury. When there are no obvious signs of any medical condition or physical injury, a diagnosis of Idiopathic Toe Walking (ITW) is made. ITW children habitually walk on their toes, however can modify their gait and walk with a heel-toe gait if they want to. Correct gait assessment in ITW children therefore becomes difficult. To solve this problem, we have developed an automated way to assess the gait in ITW children using a dual axis accelerometer. Heel acceleration data was recorded from the gait of ITW children using boots embedded with the sensor in the heel and interfaced to a handheld oscilloscope. An innovative signal processing algorithm was developed in IgorPro to distinguish toe walking stride from normal stride using the acceleration data. The algorithm had an accuracy of 98.5%. Based on the statistical analysis of the heel accelerometer data, it can be concluded that the foot angle during mid stance in ITW children tested, varied from 36° to 11.5° while as in normal children the foot stance angle is approximately zero. This algorithm was later implemented in a system (embedded in the heel) which was used remotely to differentiate toe walking stride from normal stride. Although the algorithm classifies toe walking stride from normal stride in ITW children, it can be generalized for other applications such as toe walking in Cerebral Palsy or Acquired Brain Injury subjects. The system can also be used to assess the gait for other applications such as Parkinson's disease by modifying the algorithm.
Walking barefoot on a gravel surface significantly improved gait in children with idiopathic toe walking, according to research presented here at the American Orthotic & Prosthetic Association National Assembly