Toe walking 10 y/o

Members do not see these Ads. Sign Up.

Hi Everyone

Yesterday I saw a 10 year old boy who was a toe walker. He has been doing it since his first steps, and even stands on his toes when not walking. He is as far up onto the toes as possible. He can stand and walk with 'normal' gait when he thinks about it and had nothing significantly outstanding with bmx. He did have a gastroc equinus as expected but it is not significant enough to be affecting him and more likely a symptom of standing on the toes for 10 years!

The reason for visiting the clinic was because of pain of the dorsal surface of the navicular which i think may be tendinopathy of the long extensor tendons. He also had quite a large bony prominance on the dorsal navicular.

Has any one seen this before and have any ideas for further investigations/ differential diagnosis? My next step was going to be to give him some drills/ exercises to get him walking with a heel toe gait and maybe refer for neuralogical testing. He did not show any other signs of neuralogical problem though.


Regards,
Matt Macleod

 

Hi Matt,

Have you thought about a possible os navicularum being aggrevated by the post tib tendon secondary to chronic conccentric loading?

Regards,

Daniel

 

Are you wanting to find a cause of the pain or get him to walk heel - toe?

Walking heel - toe for 5 min does the pain diminish at all?

What is your location please?

 

I dont think the pain is related to the post tib as it is palable right over the long extensor tendons and worsens with active dorsiflxn. I have got xrays and there appears to be no bony deformity an no os navicular.

I believe the cause of the pain is due to overload in these tendons due to walking with the toes in a maximally dorsiflexed position. So yes I do want to try and get him walking heel to toe. The pain worsens with activity and as initial tx i am getting him to try and walk heel toe so I will see on review next week if this helps the pain.

I just thought that it was unusual for a child to walk so far up on the toes and if any one has seen this/ has any ideas for treatment/ coaching him to walk heel toe,

My location is Auckland, New Zealand

 

Have seen many times. I'd say first port would be a neuro assessment if it isn't something you have seen much of, then treat the pathology.

Increase the length of the plantarflexers, increase the strength of the dorsiflexors. Your unvalidated treatment options are as long as a piece of string, as are the opinions on their usefulness. I'd also read through the past posts, there is some great advice scattered through there.

 

Provided that his neuro workup his normal, I have used the following method for many years to treat idiopathic digigrade gait (toewalking).

Ankle manipulation is a must. This kids are virtually always equinus. Make sure you teach them how to stretch their calves....but after they are manipulated. Second, fabricate a CFO for him, and use some type of 1st c/o to mobilize the 1st MTP joint when they walk. Functional hallux limitus is also a factor. Third, use SBR or other suitable heel lift material to allow heel contact, particularly if there is no heel strike during walking. Then, the most successful part of the plan is to add a PPT (poron) heel lift. This very successfully dampens the rebound at heel strike, and slows the bouncy heel lift. Outcomes take 2-3 months to be successful.

Howard

 

Just wondering Howard, what is it that you think is the key to the success in that treatment, post the strength/stretch program?

Is it a change in the biomechanics or the fact you made a device that increases/changes the timing of ground contact and then when ground contact is increased over a larger surface of the foot, it increases proprioceptive feedback due to the components of the type of material you have chosen?

 

Gait style is habitual. The focus of the care is to change the habit.

There are usually several factors. Equinus is the most common. When equinus is coupled with Functional hallux limitus, there is a strategic solution to prevent the 1st MTP joint from locking and accommodates the equinus....toe walking. If the MTP joint is flexed...it cannot lock. By placing them in an orthotic which prevents the Fhl from developing, and one which additionally changes the heel bounce habit, a successful outcome is very possible.

Howard

 

It comes back to the old chestnut though, what is equinus? Also, the habit vs equinus, if the equinus wasn't there to begin with, what caused the habit to start and if you haven't identified that cause to begin with, how will you eliminate it past equinus resolution. I have no answer, lots of ideas, but no answer. Just wondering what you thought?

I see plenty of toe walkers than have no neuro and no equinus, especially in the 4-6 age group. Would you treat them the same with the same thinking?

 

Please read the paper below as it explains the relationship between fibula translation and ankle equinus. While equinus can be a fixed osseous deformity...it is far more often related to a restriction in fibula translation. It should answer a lot of your questions about "what is equinus".


Dananberg, HJ, Shearstone, J, Guiliano, M “Manipulation Method for the Treatment of Ankle Equinus, “ Journal of the American Podiatric Medical Association, 90:8 September, 2000 pp 385-389

Howard

 

Hi Matt

Has the child seen, or have you thought about referring the child to a paediatric OT? There may be a sensory issue as to why he is toe walking that needs to be addressed.

Ann

 

Thanks everyone for posting on this. I havent replied for a while. I have still been working with this patient. I have sent him to 2 paed specialists for neuro testing and so far nothing has come up. One of them wanted to serial cast him but given he has adequite ROM then I cant see how this will help. The other wants to leave it alone for now.

It would appear that the toe walking is completly habitual. I found out from the mother that he spent a lot of time in a 'walker' when he was a baby because due to an operation he could not lay flat. I think this may be where the habit developed.

He has no real issue with toe walking and the parents arent too worried but are concerned about the possibility of issues in the future. My treatment so far includes stiff soled shoes, stretching of gastrosoleus, strenthening of tib ant, and re training. He has had some success and is finding heel toe walking easier but still has to think about it. It looks more natural as well. when he does toe walk it seems lower to the ground.

I am just concerned that I am doing the right thing trying to retrain his gait. with one surgeon wanting to cast and the other wanting to leave it I have kind of taken the middle ground. There are also some opinions to leave it alone and he will grow out of it but he is already 10 y/o. It seems like with gait re training it is going to be a very long drawn out process.

Thoughts?

 

There is am good long term studies that say that regardless of what you do, they will continue to toe walking into adulthood which makes the treatment difficult. This is regardless of the habitual nature suggesting there maybe something underlying however quite benign.

Casting is often used to increase functional range and does so quite well. It can also force him to walk for a set time with his heels down which helps in increasing muscle memory and a bit of sensory training. Does he toe walk in the shoes? You could also reinforce the shoes with a graphite plate and there is some work being down in a Melbourne Hospital with full length orthotic having good results while the kids are in them.

I think though you are on the right path, keep the muscle long and the other muscles strong. I agree with a previous poster though about OT, some people have success with treating this sensory however it's success is purely anecdotal.

 

Cheers for the advice. Thats what I have found too. Nothing seems to work for sure and every 'expert' seems to have a different idea. Latest up date is that maybe he has very mild CP or had a small stroke during an operation when he was a baby.

I have just crafted some ful length insoles for him out of 4mm polypro with a 1st ray c/o. Going to add in some treadmill walking (he cant walk on his toes on that!) and some activities with normal walking and doing other activities. Kinda like patting your tummy and rubbung your head type thing.

Will look into some OT in the area.

 

If he has mild CP it will be more beneficial to go with a night splint. The plate won't do much as it will be the complex dynamic of the tight gastroc/hamstring/hip flexor and possibly adductor that kicks in at heel strike making the heel strike absent rather than the habit (which the heel plate helps with). Check out when he is treadmill walking how much compensation through a crouch type gait he has. Generally these kids need hamstring and flexor stretching also.

Sensory processing with an OT also won't help if it is CP, good neuromuscular physiotherapy at the local children's hospital will though.

I think this highlights the importance of a diagnosis to help aid the appropriate treatment path. Such a small thing, makes such a dramatic difference.

Good on you for hanging in there.

 

Also as an observation, not a criticism, this shows the necessity for full comprehensive history taking, including all familial history.

What operation was this? They were a baby, but were they walking yet and did this have any affect?

Enjoying the post and keep up the good work.

Cheers, :drinks

James

 

The operation he had was for a tracheo-oesophageal abnormality in which his stomach was moved up due to lack of an oesophagus. This was before he was walking but it was because of this he could not lie flat. The latest 'expert' to see him does not think that time in the walker was a cause for his walking but I disagree. It is common sense I think. So far they have still found nothing. Both the orthopods have even disagreed on his dorsiflexion ROM! One found him to have good ROM the other an equinus...interesting.

I have given him some 4mm polypro plates with a large 1st ray cut out and he found them great straight away. He found it much easier to walk 'normally' due to the 1st ray c/o and when he attempted to go onto his toes to walk he couldn't. I think I might be onto something. Haven't had the panicky mother phone call and its been a week so I guess no news is good news. I will see him again this week and will update then. Thanks for everyones input...looks like im finally getting somewhere.

Might have to teach a few orthopedic surgeons in New Zealand a thing or two if this is successful!

 

Hi all,

I'm a bit lost with how the orthotic plate with the 1st ray cutout works. You want to encourage all of the ankle joint dorsiflexion range available to be used instead of MPJ extension. To make the foot not bend, you reinforce it with the stiff flat plate. Am I right so far?

How does that fit in with a cutout which encourages the 1st MPJ to bend?

Thanks for your help.

Rebecca

 

Are you wanting to find a cause of the pain or get him to walk heel - toe?

Walking heel - toe for 5 min does the pain diminish at all?

What is your location please?
Onindita
Bangladesh

 

I'm confused, are you now saying he doesn't have CP?

Has he seen a neurologist? They should be the first specialist in atypical toe walking rather than the ortho. Most toe walking is neurological based, rarely is it muscular/idiopathic.

Glad though it appears to be reducing the pain, trick is now to make it long term and continue to ensure there is no underlying diagnosis.

 

i saw a similar case to this,

8y/o happy healthy kid with autism and a equinus during gait, but >50 degrees of passive ankle DF. child had been investigated for CP, but not diagnosis made. no pain or complaints from the kid, but a very concerned mum

gait showed forefoot strike, rearfoot dropped close to the ground (but never touched) during midstance, then fairly normal propulsion. massivley internally rotated throughout gait.

added a heel lift external to the shoe, in an attempt to get heel contact. once the gait began with heel contact, immediate improvement. it was a completely different gait.

reduced the size of the lift over time, all better!