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Hi all,
I thought I would share a case with you all in the hope of some further input. I have a 9 year old very active female who presented to the clinic with parental concerns regarding toe walking. Her parents had noticed this habit start approx 12 months ago and feel that she had progressively increased the amount of time spent walking on her toes in the last 3 months. Previous consultations with other health professionals had resulted in stretching exercises and heel lifts.
Examination revealed a significant soft tissue equinus of both feet. Ankle joint dorsiflexion ROM testing revealed a signifcantly reduced value of 30 degrees
(norm 42-52). The patient had reported difficulty with prolonged activity with pain in the gastroc/soleus muscle complex in the last 3 months with prolonged physical activity ending in tears. There appeared to be no bony blockage in ankle joint range of motion and there was an absence of neurological complications.
My initial consultation resulted in modified stretching exercises , footwear modifications (heel lift and rigid forefoot) and activity modification. A review four weeks later revealed a significant improvement in ankle joint Dorsiflexion ROM (38) but the pain post activity had actually worsened. I am a bit lost as to the pathomechanics of the pain actually getting worse with improved ankle joint ROM??
My next step was going to be a period of night splinting in a strassbourg sock, but am sceptical as to wether this will reduce her discomfort. Any thoughts on the managment of this child. When should I consider a surgical opinion considering the absence of neurological symptoms and improvement in ROM with stretching???
Possibly use a nightsplint (custom moulded AFO) combined with a full length knee gaiter. The gaiter will maintain the knee in full extension thus ensuring best possible stretch on gastrocs. I would explore this option before looking at more invasive options
Children going through growth spurts often lose muscle flexibility from my observations.
Especially in the gastrocs and hamstrings, as their skeletal development grows upwards, the muscle is slow to lengthen to keep up - the long muscles crossing articular junctions especially. The sporty kids are worse as their activity encourages tone and strength in the muscle - at the expense of length and flexibililty. They NEVER stretch to compensate! Lots of stretching is needed. Passive with parental help, self directed from the child and night splinting may all be useful - especially after any activity, and again an hour or so after activity end. Sure the pain is within the muscle body, and not the calcaneal epiphiseal plate?
Low dye strapping is very useful. Better make sure the 'Sport Billy' isn't partaking in trampolining!
As an ex 'sufferer' myself who was dragged to many specialists, had to endure calipers, hard orthotics and the hideous shoes that went with them, not to mention scare stories of surgery, I simply grew out of it...when I went to secondary school and was allowed to wear heels... I'm 48 now and have no lasting problems.
My advice..ignore it...Please! Once Mummy has made a fuss the attention is wonderfull! I know!
Hi all,
When should I consider a surgical opinion considering the absence of neurological symptoms and improvement in ROM with stretching???
Now. 9 y/o, no neuropathology, no boney blocking - percutaneous ach len... It sounds good to be. Has worked very well for me. I like to cast for a little longer than the lit suggests, 6-9 weeks.
Maybe we need to clarify some terminology - a "habitual" toe walker by definition is a toe walker that has no pathology... ie they do it out of habit. Its a common cause of toe walking and needs NO intervention --> they always come right (unless they have some sort of tactile defensive pathology)
The patient on the first post has an equinus --> not a habitual toe walker.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
Dear Craig,
oh how I agree, what I was trying to say, having been on both sides of the fence, is once it is established as 'habitual' then leave well alone. Too often we are cajoled by pushy parents (my Mum bless her) into intervening when none necessary, the attention even prolonging the issue.
In the two I have treated one was 'habitual' (wannabe dancer)& one was undignosed cerebal palsy (immigrant child) Both sucessfully treated.
I am not sure I understand Craig. Can't the habit of toe walking lead to the equinus or are you saying the equinus has led her to toe walk? bit like the chicken or the egg scenario.
There seems to be alot of conjecture with regards to treatment here.
To bring everyone up to speed I have continued to treat the equinus ie heel raises and stretches and have also trialled low dye taping with sport. This is still not getting any results in response to pain management. The child is still complaing of medial belly mid portion gastroc pain. I Am trying to source a childs size strassbourg sock as mum has reservations about the child complying with a righid night splint such as an aquaplast splint.
Outcome of patients after Achilles tendon lengthening for treatment of idiopathic toe walking. J Pediatr Orthop. 2006 May-Jun;26(3):336-40
Hemo Y, Macdessi SJ, Pierce RA, Aiona MD, Sussman MD
Quote:
Fifteen children who were diagnosed with idiopathic toe walking that cannot be corrected by nonoperative treatment were assessed by clinical examination and computer-based gait analysis preoperatively and approximately 1 year after Achilles tendon lengthening. Passive dorsiflexion improved from a mean plantarflexion contracture of 8 degrees to dorsiflexion of 12 degrees after surgery. Ankle kinematics normalized, with mean ankle dorsiflexion in stance improving from -8 to 12 degrees and maximum swing phase dorsiflexion improving from -20 to 2 degrees. Peak ankle power generation increased from 2.05 to 2.37 W/kg but did not reach values of population norms. No patient demonstrated clinically relevant triceps surae weakness or a calcaneal gait pattern. Seven patients had a stance phase knee hyperextension preoperatively, and 6 of these corrected after surgery. Achilles tendon lengthening improves ankle kinematics without compromising triceps surae strength; however, plantarflexion power does not reach normal levels at 1 year after surgery.
I am a student of Podiatry from AUT University in NZ. I was curious to whether your 9 year old patient is showing a positive helbing's sign (aka medial bowing of the achillis) and have you thought about posting a medial wedge to 'straighten' the tendon. I have also read and heard that manipulation has helped improve ROM at the ankle. (Manipulation Method for the Treatment of Ankle Equinus by Menz and Dananberg JAPMA 2001; 91(2) 105-106).
Rear foot frontal plane mechanics are normal. I have tried manipulating the head of the fibula after ankle joint dorsiflexion testing and have re-tested but have found little difference in the results. I think if anything the joint "feels" more mobile ie quality of motion, in passive talo crural examination but have found fibula manipulation to have no effect in actually improving the range of motion
Rear foot frontal plane mechanics are normal. I have tried manipulating the head of the fibula after ankle joint dorsiflexion testing and have re-tested but have found little difference in the results. I think if anything the joint "feels" more mobile ie quality of motion, in passive talo crural examination but have found fibula manipulation to have no effect in actually improving the range of motion
I am a clinical specialist orthotist in the UK. I have seen a number of patients with very similar case history.
Anecdotally i have found that heel lifts, rigid soled footwear and nightsplints have little effect on these patients.
Have you checked for proximal weakness? Weak hip extensors/tight hip flexors is a common finding in these patients as is poor core stability in the trunk. Toe walking significantly alters the effect of the ground reaction force (GRF) effect on required muscle activity in hip extensors. The most common example of this is duchenne muscular dystrophy and its known associated conditions. By toe walking and increasing lumbar lordosis the GRF is translated behind the hip generating hip extension moments therefore assisting in hip extension and reducing the muscular effort required by the patient. If the patient continues to go onto their toes in the presence of a rigid extension to the sole plate of the shoe it is likely there is an element of hip extensor weakness/hip flexor tightness.
Hopefully a detailed physiotherapy exam and programme can resolve this unless their is an undiagnosed neurological condition.
If this is not the case then their are orthotic devices that can assist. Static positioning for these patients in order to get a stretch is often uneventful and poorly tolerated. There are increasing dynamic systems that can provide an extension torque across the knee, ankle and hip. The most common systems can be seen at www.ultraflexsystems.com (from memory).
I am very aggressive in managing this condition. Rigid AFO's (ankle foot orthoses) custom made with an adjustable plantarflexion limiting hinge and free dorsiflexion is my preferred option. Heel raises are added externally and reviewed weekly in conjuction with intense physio and personal physio programme to strengthen proximal extensors and stretch hip flexors.
Even when the patient is able to walk with a heel toe gait, the hinged AFO's with plantarflexion limitation are maintained to prevent recurrence of toe walking through growth.
Articulating AFO's allow the dorsiflexors to remain active while blocking various ranges of plantarflexion. Static (rigid) afo's are likely to cause disuse atrophy particularly to the dorsiflexors. They also allow the range of motion of the ankle joint to be controlled and easilt altered. Also more cost effective. Does require regular modification to heel raise but tolerance is better.
Articulating AFO's allow the dorsiflexors to remain active while blocking various ranges of plantarflexion. Static (rigid) afo's are likely to cause disuse atrophy particularly to the dorsiflexors. They also allow the range of motion of the ankle joint to be controlled and easilt altered. Also more cost effective. Does require regular modification to heel raise but tolerance is better.
Simon
Hi Simon,
would your criteria remain similar with gastroc tightness
would your criteria remain similar with gastroc tightness
ta
Declan
Not necessarily, i do a lot of serial casting but remove an anterior wedge from the cast at the anterior ankle so the cast slowly deforms allowing increased ankle dorsiflexion. Always a long leg cast though otherwise gastroc tightness may caused increased knee flexion
Not necessarily, i do a lot of serial casting but remove an anterior wedge from the cast at the anterior ankle so the cast slowly deforms allowing increased ankle dorsiflexion. Always a long leg cast though otherwise gastroc tightness may caused increased knee flexion
Simon
good concept re long leg cast and anterior wedge with deformation. Getting back to articulating AFO's I feel that they are often incorrectly used in situations where there may be adequate ROM at TCJ (full knee extension) but proximal knee/hip muscle weakness results in crouch.
Do we not get best stretch on gastrocs in 3rd rocker in gait when extension moment is greatest?
Classification of idiopathic toe walking based on gait analysis: Development and application of the ITW severity classification. Gait Posture. 2006 Dec 8;
Alvarez C, De Vera M, Beauchamp R, Ward V, Black A
Quote:
Idiopathic 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).
The purpose of this study was to use muscle-actuated forward dynamic simulations to quantify individual muscle contributions to body support (vertical ground reaction force) and propulsion (horizontal ground reaction force) and the mechanical energetics of the body segments during toe and heel-toe walking performed by able-bodied subjects to identify possible compensatory mechanisms necessary to toe walk. The simulations showed that an increased magnitude of plantar flexor power output in early stance, which was necessary to maintain the equinus posture during toe walking, contributed to body support and acted to brake (decelerate) the center-of-mass in the horizontal direction. This in turn required a reduction in the contributions to support from the vastii, gluteus maximus and biarticular hamstring muscles and decreased contributions to braking from the vastii and to a lesser extent the gluteus maximus. In late stance, the soleus contributed less to body support and forward propulsion during toe walking, which when combined with the increased braking by the plantar flexors in early stance, required a prolonged contribution to forward propulsion from the hamstrings from mid- to late stance. The multiple compensatory mechanisms necessary to toe walk have important implications for distinguishing between underlying pathology and necessary compensatory mechanisms, as well as for identifying the most appropriate treatment strategy for equinus gait.
What are all the assessments we should be doing when a toe walker somes into the clinic?
1. Gait (eg use of 3 rockers)
2. Neuro assessment (eg cerebral palsy)
3. Behavioural history (eg autism)
4. Bioeval (eg limited RoM)
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
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.
What are all the assessments we should be doing when a toe walker somes into the clinic?
Birth history - prematurity, low birth weight, TEV etc are risk factors for CP or Sensory integration disorders (SID)
History - trauma related
Familial - CMT, MD, idopathic
Neuro - reflexes, tone, quality of muscle movement - for CP
Biomech - equinus involvement
Behavioural - autism, SID
Am currently working on tool to help clinicians with this based on the evidence. Stay tuned....
__________________
Cheers,
Cylie.... in a permanent state of confusion
Detecting Idiopathic toe-walking gait pattern from normal gait pattern using heel accelerometry data and Support Vector Machines.
Pendharkar G, Lai DT, Begg RK. Conf Proc IEEE Eng Med Biol Soc. 2008;1:4920-4923.
Department of Electrical and Computer Systems Engineering, Monash University, Melbourne 3168, Australia.
Quote:
Toe walking is commonly seen in children with neurological symptoms such as cerebral palsy. However idiopathic toe walking (ITW) in children is considered to be habitual. ITW children are categorized as toe walkers without any neurological problems, however they walk with their foot plantar-flexed. These children often suffer poor sport performance leading to low exercise levels and the associated consequences. If the condition is not treated, the ITW children eventually develop abnormal gait pattern as adults and could suffer from postural problems. However, ITW gait is difficult to observe since children can modify their gait when made aware of it. Gait analysis using heel accelerometry data in ITW children could provide an objective and quantitative description of their toe walking and may thus be beneficial for observing ITW. In this paper, we propose a technique based on Support Vector Machines (SVM) to recognize ITW gait patterns using heel accelerometry data. Test results indicated that the SVM is able to identify ITW gait patterns with a maximum accuracy of 87.5% when a feature selection algorithm was applied.
Habitual toe walker
Linear Mode
