Idiopathic toe walking

Question 1

What is idiopathic toe walking?

Answer 1

-walking on forefoot the stance phase of the gait cycle

-prevalence: 5.5-12%

-no heel contact

-no known medical cause

-unilateral toe walking is RED FLAG

Question 2

Diff dx idiopathic toe walking

Answer 2

NEUROLOGICAL
-CP
-hereditary spastic paraparesis

NEUROMUSCULAR
-MD
-charcot-marie-tooth
-spinal muscular atrophy

OTHER BRAIN OR SC ABNORMALITIES
-spina bifida
-tethered cord
-brain or SC tumor

ORTHO
-talipes equinovarus (club foot)

Question 3

ITW is a diagnosis of exclusion- ETIOLOGY

Answer 3

ETIOLOGY
-unknown!
-neurological, neuromuscular, neuropsych, ortho disease, or other disorders of the central or peripheral NS are ruled out
-may have genetic component

Question 4

Common comorbidities

Answer 4

neuropsych dods- ADHD, anxiety

sensory processing disorders

speech delays

Question 5

Impact of ITW

Answer 5

-Diminished dorsiflexion ROM is
associated with foot and ankle
pain/pathology later in life

-risk of injury and deformity: pain, frequent falls, ankle sprain, postural compensations, bony changes with development

-social aspects of development
–fatigue/inability to keep up with peers, bullying, social isolation

Question 6

When does heel strike typically emerge?

Answer 6

18-24 months of age

Question 7

primary impairments ITW

Answer 7

-unknown, but common impairments:

-ADHD/anxiety
-oculomotor and/or vestibular impairments
-concern for ASD
-sensory processing impairments

Question 8

Secondary impairments ITW

Answer 8

-limited DF ROM
-short hamstrings
-muscle weakness/poor PF power generation
-impaired balance
-pain –> with more severe limitations
-pronation and/or knee hyperextension

**supination is a red flag

Question 9

Oculomotor/vestibular invovlement

Answer 9

-common among those with ITW

34-44%

Question 10

Systems review - key areas to assess

Answer 10

-when did toe walking start?
–> sudden or late onset is a red flag
-familiy/med history
-birth and developmental history
-sensory and behavioral history
-percentage of time on toes - in shoes or barefoot?

Question 11

Calf weakness and ITW

Answer 11

-limited power production–> limited rapid ankle PF

-compensation for calf weakness or poor power production–> decrease functional DF ROM to limit required power production

Question 12

Intervention for ITW

Answer 12

0-10 degrees DF with knee extended: stretching, night splints, heel wedging to accommodate

<0 degrees with knee extended: serial casting, ortho surgery, botulinum toxin, may consider serial night splinting

Question 13

Interventions to consider after DF range is normalized

Answer 13

orthotic support - foot orthotics, UCBL orthotics, SMOs, AFOs

stretching -

balance- target vision, vestibular, or proprioceptive components

strengthening

gait training

manual therapy

Question 14

Goals for treatment

Answer 14

10-15 DF with knee extended- in subtalar neutral

toe walking <25% of time throughout day

no pain

age-appropriate gross motor skills

age-appropriate tripping/falling

stretching program

LENGTH: can be 1-2 year process due to high risk for recurrence

Question 15

Notes from CPG to be published next year

Answer 15

FIRST PRIORITY OF INTERVENTION : address ankle DF ROM limitations

-serial casting recommended for less than 10 degrees DF with knee extension

-gait training with orthotics

-PT interventions to address impairments and activity limitations associated with TW

-shared decision making with family