toe walking Flashcards
idiopathic toe walking is characterized by:
walking through stance phase of gait cycle
bilateral and symmetrical (unilateral is a red flag)
primary impairments
Typically, positive exam findings in one or more of the following:
ADHD/anxiety
Oculomotor and/or vestibular impairments
Concern for Autism Spectrum Disorder
Sensory processing impairments (ie, sensory seeking or sensory avoiding)
secondary impairments
Limited dorsiflexion ROM (<10 degrees knee ext)
Short hamstrings
Muscle weakness/poor PF power generation
Impaired balance
Pain
Pronation and/or knee hyperextension
Pronation is a common compensation for limited DF ROM
Supination is a red flag
evaluation
Subjective History and Systems Review – Key Areas to Assess:
Family and medical history
Birth and developmental history
Sensory and behavioral history
When did the toe walking start (sudden or late onset is a red flag)
Percentage of time on toes, are there patterns?
diagnosis of exclusion
etiology - unknown
neurological, neuromuscular, neuropsychiatric, orthopedic disease, other CNS or PNS systems ruled out
ITW can have genetic component
differential diagnosis - neurological
CP, hereditary spastic paraparesis
Diff Dx - neuromuscular
Muscular dystrophy, Charcot-marie-tooth, spinal muscle atrophy
Diff Dc - other abnormalities
spina bifida, tethered cord, brain or SC tumor
Diff Dx - orthopedic
talipes equinovarus (club foot)
common comorbidities
neuropsychiatric disorders - ADHD, anxiety, sensory processing disorders, speech delays
why do we care
Diminished dorsiflexion ROM is associated with foot and ankle pain/pathology later in life
Risk of injury/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
typical gait development
Heel strike typically emerges around 18-24 months of age
Toe walking can be a new walker gait pattern occasionally
Habitual toe walking is not considered a typical part of development
exam items
Gait analysis
ROM
Soleus/gastric length testing
Functional assessment
Cape and PAC
calf weakness
Limited power production Limited rapid ankle plantar flexion
Compensation for calf weakness or poor power production is to decrease functional DF ROM to limit required power production
Due to active insufficeny because the movement arm is shortened.
Know that its common and this is why
intervention - limited DF ROM requires foot management
10+ dg w knee ext = stretching program to maintain
0-10 dg w knee ext = stretching program, night splints, heel wedging
< 0 dg w knee ext = serial casting, orthopedic surgery, botox
other interventions after DF ROM is normal
Orthotic support – foot orthotics, UCBL orthotics, SMOs, AFOs
Stretching
Balance – vision, vestibular, and/or proprioceptive components
Strengthening
Gait training
Manual therapy
goals for Tx
10-15 degrees dorsiflexion with knee extended (in subtalar neutral!)
Toe walking <25% of the time throughout the day
No pain
Age-appropriate gross motor skills
Age-appropriate tripping/falling
Stretching program to manage calf length particularly during growth spurts
Treatment for ITW can be 1-2+ year process due to high risk for recurrence
