Toe walking

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Toe walking
Toe Walking in Autism 1.jpg
Toe walking in an autistic young woman
SpecialtyPediatrics

Toe walking refers to a condition where a person walks on their toes without putting much weight on the heel or any other part of the foot. Toe walking in toddlers is common. These children usually adopt a normal walking pattern as they grow older. If a child continues to walk on their toes past the age of three, they should be evaluated by a doctor.[1]

Toe walking can be caused by different factors. One type of toe walking is also called "habitual" or "idiopathic" toe walking, where the cause is unknown.[2] It should only be diagnosed after all other conditions have been excluded. [3] Other causes include a congenital short Achilles tendon, muscle spasticity (especially as associated with cerebral palsy) and paralytic muscle disease such as Duchenne muscular dystrophy.[4] A congenital shortening of the Achilles tendon can be hereditary, can take place over time as the result of abnormal foot structure which shortens the tendon, or can shorten over time if its full length is not being used. Toe walking is sometimes caused by a bone block located at the ankle which prevents the antagonist movement, dorsiflexion. This cause is often associated with trauma or arthritis.[5] It may also be one way of accommodating a separate condition, foot drop. Persistent toe walking in children has been identified as a potential early sign of autism.[6][7]

It is estimated that 5% of healthy children are diagnosed with idiopathic toe walking.[8] Idiopathic toe walking has also been found to be more prevalent in males than females when tested with very large numbers of children. This study looked for family history of toe walking and the connection to children demonstrating idiopathic toe walking (ITW).There 64.2% of children with ITW who were male and 348 children with a positive family history of toe walking. This means idiopathic toe walking may have a genetic link. [9] In 30–42% of children with idiopathic toe walking, a family link has been observed.[10]

Cause[edit]

Unknown[edit]

Idiopathic toe walking is always bilateral (or on both sides) and has no orthopedic or neurological cause. It is diagnosed after if it continues past the age of three.[11] In this condition, children are able to voluntarily walk with the typical heel-toe pattern, but prefer to walk on their tip toes. In order for it to be considered idiopathic, the child's medical history should be clear of any neurological, orthopedic, or neuro-psychiatric conditions including other gait abnormalities.[12] [13] It is thought to be related to sensory processing challenges.[14][15] Two classifications of idiopathic toe walking have been established. The Alvarez's classification identifies the severity of the dysfunction based upon kinematics and ankle rockers. The Pomarino classification identifies the toe walking according to the individual's specific characteristics and characterizes them into three types based on the signs presented. [16]

Cerebral palsy[edit]

Studies have been performed to determine the source of the association between toe walking and cerebral palsy. One study suggests that the toe walking—sometimes called an equinus gait—associated with cerebral palsy presents with an abnormally short medial and lateral gastrocnemius and soleus—the primary muscles involved in plantarflexion. A separate study found that the gait could be a compensatory movement due to weakened plantarflexion muscles.[17] In people who have cerebral palsy and toe walk, there is greater plantarflexion force required for normal heel-to-toe walking than for toe walking. When typically developing children are tasked to perform different types of toe walking, their toe walking could not reduce the force to the levels that children who toe walking with cerebral palsy have when they walk. This suggests that toe walking associated with cerebral palsy may be due to abnormally weakened plantarflexion that can only manage toe walking.[18]

Diagnosis[edit]

A doctor will typically evaluate if the toe walking affects both or one leg, what the child's range of motion is (how far they can flex their feet) and perform a basic neurological exam. Treatment will depend on the cause of the condition.[19]

Treatment[edit]

For idiopathic toe walking in young children, doctors may prefer to watch and wait: the child may "outgrow" the condition.[20] There are limited treatments that demonstrate long term walking change.[21] But there are treatments that can change the length of muscles in the short term.[4]

  • Wearing a brace or splint either during the day, night or both, limits the ability of the child to walk on their toes and stretches the Achilles tendon. One type of brace used is an AFO (ankle-foot orthosis).
  • Serial casting where the foot is cast with the tendon stretched, and the cast is changed weekly with progressive stretching. However, these casts may not be changed weekly and instead every 2–3 weeks.
  • Botox therapy may be used to paralyze the calf muscles to reduce the opposition of the muscles to stretch the Achilles tendon, usually together with serial casting or splinting, however, one small study has shown this has limited impact.
  • If conservative measures fail to correct the toe walking after about 12–24 months, surgical lengthening of the tendon is an option. The surgery is typically done under full anaesthesia but if there are no issues, the child is released the same day. After the surgery, a below-the-knee walking cast is worn for six weeks and then an AFO is worn to protect the tendon for several months.

For toe walking which results from more serious neuro-muscular conditions, additional specialists may need to be consulted.

References[edit]

  1. ^ "Toe Walking". Mayo Clinic. Archived from the original on 2007-06-03. Retrieved 2007-06-24.
  2. ^ Babb A, Carlson WO (2008). "Idiopathic toe-walking". South Dakota Medicine. 61 (2): 53, 55–7. PMID 18432151.
  3. ^ Williams, C; Tinley, P; Curtin, M (2010). "The Toe Walking Tool: a novel method for assessing idiopathic toe walking children". Gait & Posture. 32 (4): 508–11. doi:10.1016/j.gaitpost.2010.07.011. PMID 20692159.
  4. ^ a b "Toe Walking". emedecine.com. Archived from the original on 2007-06-01. Retrieved 2007-06-07.
  5. ^ "Equinus Deformity at Foot Associates of Central Texas, LLC". 2009. Archived from the original on 2013-12-08. Retrieved 2013-12-11.
  6. ^ Sala DA, Shulman LH, Kennedy RF, Grant AD, Chu ML (1999). "Idiopathic toe-walking: a review" (PDF). Developmental Medicine & Child Neurology. 41 (12): 846–8. doi:10.1017/S0012162299001681. PMID 10619285.
  7. ^ Geschwind DH (2009). "Advances in autism". Annual Review of Medicine. 60 (1): 367–80. doi:10.1146/annurev.med.60.053107.121225. PMC 3645857. PMID 19630577.
  8. ^ Engstrom, P; Tedroff, K (2012). "The prevalence and course of idiopathic toe-walking in 5-year-old children". Pediatrics. 130 (2): 279–84. doi:10.1542/peds.2012-0225. PMID 22826572. S2CID 2915651.
  9. ^ Pomarino, David; Ramírez Llamas, Juliana; Pomarino, Andrea (2016). "Idiopathic Toe Walking Family Predisposition and Gender Distribution". Foot & Ankle Specialist. 9 (5): 417–422. doi:10.1177/1938640016656780. PMID 27370652. S2CID 1160638.
  10. ^ Pomarino, David; Ramírez Llamas, Juliana; Martin, Stephan; Pomarino, Andrea (16 January 2017). "Literature Review of Idiopathic Toe Walking: Etiology, Prevalence, Classification, and Treatment". Foot & Ankle Specialist. 10 (4): 337–342. doi:10.1177/1938640016687370. PMID 28092971. S2CID 3389265.
  11. ^ Stricker, S (1998). "Idiopathic toe walking: a comparison of treatment methods". Pediatr Orthoped. 18 (3): 289–93. doi:10.1097/00004694-199805000-00003. PMID 9600550.
  12. ^ Williams, C; Tinley, P; Curtin, M (2010). "The Toe Walking Tool: a novel method for assessing idiopathic toe walking children". Gait & Posture. 32 (4): 508–11. doi:10.1016/j.gaitpost.2010.07.011. PMID 20692159.
  13. ^ Kuijk, A; Kosters, R; Vugts, M; Geurts, A (2014). "Treatment for idiopathic toe walking: A systematic review of the literature". Journal of Rehabilitation Medicine. 46 (10): 945–957. doi:10.2340/16501977-1881. PMID 25223807.
  14. ^ Fanchiang, H; Geil, M; Wu, J; Ajisafe, T (2016). "The Effects of Walking Surface on the Gait Pattern of Children With Idiopathic Toe Walking". Journal Child Neur. 31 (7): 858–863. doi:10.1177/0883073815624760. PMID 26733505. S2CID 5526538.
  15. ^ Williams, C; Tinley, P; Curtin, M; Wakefield, S; Nielson, S (2014). "Is Idiopathic Toe Walking Really Idiopathic? The Motor Skills and Sensory Processing Abilities Associated With Idiopathic Toe Walking Gait". Journal of Child Neurology. 29 (1): 71–78. doi:10.1177/0883073812470001. PMID 23349518. S2CID 5696959.
  16. ^ Pomarino, David; Ramírez Llamas, Juliana; Martin, Stephan; Pomarino, Andrea (16 January 2017). "Literature Review of Idiopathic Toe Walking: Etiology, Prevalence, Classification, and Treatment". Foot & Ankle Specialist. 10 (4): 337–342. doi:10.1177/1938640016687370. PMID 28092971. S2CID 3389265.
  17. ^ Hampton, DA, Hollander, Kw, Engsberg, JR (2003). "Equinus Deformity as a Compensatory Mechanism for Ankle Plantarflexor Weakness in Cerebral Palsy" (PDF). Journal of Applied Biomechanics. 19 (4): 325–339. doi:10.1123/jab.19.4.325. Retrieved 2013-12-11.CS1 maint: multiple names: authors list (link)
  18. ^ Wren, T. A.; Do, K. P.; Kay, R. M. (2004). "Gastrocnemius and soleus lengths in cerebral palsy equinus gait: differences between children with and without static contracture and effects of gastrocnemius recession". Journal of Biomechanics. 37 (9): 1321–7. doi:10.1016/j.jbiomech.2003.12.035. PMID 15275839.
  19. ^ "Toe Walking". orthoseek.com. Archived from the original on 2007-09-19. Retrieved 2007-06-07.
  20. ^ "Toe Walking". mastersofpediatrics.com. Archived from the original on 2007-06-08. Retrieved 2007-06-24.
  21. ^ Caserta, A; Pacey, V; Fahey, M; Gray, K; Engelbert, R; Williams, C (2019). "Interventions for idiopathic toe walking". Cochrane Database of Systematic Reviews. 2019 (10): CD012363. doi:10.1002/14651858.CD012363.pub2. PMC 6778693. PMID 31587271.

External links[edit]

Classification