Toe walking

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Toe walking
Toe Walking in Autism 1.jpg
Toe walking
Specialty Pediatrics

Toe walking is a term describing a type of walking style. Toe walking is when a person walks on their toes or the ball of their foot, without putting much or any weight on the heel or any other part of the foot. [1] Toe walking in toddlers is common. Children who toe walk as toddlers commonly adopt a heel-toe walking pattern as they grow older. If a child continues to walk on their toes past the age of three, or cannot get their heels to the ground at all, they should be examined by a health professional who is experienced in assessing children's walking. [2]

Contents

Toe walking can be associated with a number of health conditions, or have an unknown reason. When no medical reason for toe walking and no underlying condition can be identified, health professionals will commonly refer to it as "idiopathic" toe walking. This is not a formal or recognized diagnosis; rather, it is simply a term indicating that there is no identifiable reason or cause for the toe walking and that time. The child may have a diagnosis that becomes more apparent as they grow or never have a diagnosis that causes the toe walking. [3] Idiopathic toe walking should only be considered after all other conditions have been excluded. [4]

Other causes for toe walking include a congenital short Achilles tendon, muscle spasticity (commonly associated with cerebral palsy) or genetic diseases muscle disease such as Duchenne muscular dystrophy. [5] Toe walking may also be caused by a bone block located at the ankle which prevents the ankle from moving. This may be as the result of trauma or arthritis. [6] Toe walking may also be one way of accommodating a separate condition, foot drop. Persistent toe walking in children is also associated with developmental disabilities, such as Autism Spectrum Disorders. autism. [7] [8] Toe walking is commonly found in children who have been placed on the autism spectrum. [9] [10] In a recent study, 68% of children with an Autism Spectrum Disorder report experiencing walking changes. [11] [12]

It is estimated that 5% of healthy children have no reason for their toe walking (idiopathic toe walking). [13] Idiopathic toe walking has also been observed more in males than females when very large groups of children with toe walking are observed. One study looked for a family history of toe walking, and found a connection with family members all toe walking with no medical reason (idiopathic toe walking). This means there may be a genetic link with idiopathic toe walking. [14] Idiopathic toe walking spontaneously disappears over the years in the majority of cases and is most often not associated with a motor or cognitive issue. [15]

Cause

Idiopathic toe walking is always bilateral and has no orthopedic or neurological cause. It is diagnosed after if it continues past the age of three. [16] 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. [17] [18] It is thought to be related to sensory processing challenges. [19] [20] Two classifications of idiopathic toe walking have been established. The Alvarez's classification identifies the severity of the toe walking based upon kinematics and ankle rockers. [21] 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. [22]

Cerebral palsy

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. [23] 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. [24]

GLUT1 Deficiency Syndrome

Toe walking is a symptom in those with GLUT1 deficiency Syndrome. [25]

Diagnosis

There are many health professionals who assess and treat toe walking. Family physicians, neurologists, orthopaedic surgeons, pediatricians, physical therapists, physiotherapists and podiatrists are all commonly consulted. Treatment will depend on the cause of the condition. [26]

Treatment

For idiopathic toe walking in young children, health professionals may prefer to watch and wait: as the child may "outgrow" the toe walking with time. [27] There are limited treatments that demonstrate long term walking change. Many treatments instead focus on any tightness in the calf muscles that can be associated with the toe walking. [28] [5] Common treatments for idiopathic toe walking can include: [28]

For toe walking which results from other medical conditions, additional specialists may need to be consulted.

Related Research Articles

<span class="mw-page-title-main">Charcot–Marie–Tooth disease</span> Neuromuscular disease

Charcot–Marie–Tooth disease (CMT) is a hereditary motor and sensory neuropathy of the peripheral nervous system characterized by progressive loss of muscle tissue and touch sensation across various parts of the body. This disease is the most commonly inherited neurological disorder, affecting about one in 2,500 people. It is named after those who classically described it: the Frenchman Jean-Martin Charcot (1825–1893), his pupil Pierre Marie (1853–1940), and the Briton Howard Henry Tooth (1856–1925).

<span class="mw-page-title-main">Cerebral palsy</span> Group of movement disorders that appear in early childhood

Cerebral palsy (CP) is a group of movement disorders that appear in early childhood. Signs and symptoms vary among people and over time, but include poor coordination, stiff muscles, weak muscles, and tremors. There may be problems with sensation, vision, hearing, and speech. Often, babies with cerebral palsy do not roll over, sit, crawl or walk as early as other children. Other symptoms include seizures and problems with thinking or reasoning. While symptoms may get more noticeable over the first years of life, underlying problems do not worsen over time.

Spasticity is a feature of altered skeletal muscle performance with a combination of paralysis, increased tendon reflex activity, and hypertonia. It is also colloquially referred to as an unusual "tightness", stiffness, or "pull" of muscles.

<span class="mw-page-title-main">Achilles tendon</span> Tendon at the back of the lower leg

The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon at the back of the lower leg, and is the thickest in the human body. It serves to attach the plantaris, gastrocnemius (calf) and soleus muscles to the calcaneus (heel) bone. These muscles, acting via the tendon, cause plantar flexion of the foot at the ankle joint, and flexion at the knee.

The ankle jerk reflex, also known as the Achilles reflex, occurs when the Achilles tendon is tapped while the foot is dorsiflexed. It is a type of stretch reflex that tests the function of the gastrocnemius muscle and the nerve that supplies it. A positive result would be the jerking of the foot towards its plantar surface. Being a deep tendon reflex, it is monosynaptic. It is also a stretch reflex. These are monosynaptic spinal segmental reflexes. When they are intact, integrity of the following is confirmed: cutaneous innervation, motor supply, and cortical input to the corresponding spinal segment.

<span class="mw-page-title-main">Clonus</span> Set of involuntary and rhythmic muscular contractions and relaxations

Clonus is a set of involuntary and rhythmic muscular contractions and relaxations. Clonus is a sign of certain neurological conditions, particularly associated with upper motor neuron lesions involving descending motor pathways, and in many cases is accompanied by spasticity. Unlike small spontaneous twitches known as fasciculations, clonus causes large motions that are usually initiated by a reflex. Studies have shown clonus beat frequency to range from three to eight Hz on average, and may last a few seconds to several minutes depending on the patient’s condition.

<span class="mw-page-title-main">Gait (human)</span> A pattern of limb movements made during locomotion

A gait is a manner of limb movements made during locomotion. Human gaits are the various ways in which humans can move, either naturally or as a result of specialized training. Human gait is defined as bipedal forward propulsion of the center of gravity of the human body, in which there are sinuous movements of different segments of the body with little energy spent. Various gaits are characterized by differences in limb movement patterns, overall velocity, forces, kinetic and potential energy cycles, and changes in contact with the ground.

<span class="mw-page-title-main">Foot drop</span> Gait abnormality

Foot drop is a gait abnormality in which the dropping of the forefoot happens due to weakness, irritation or damage to the deep fibular nerve, including the sciatic nerve, or paralysis of the muscles in the anterior portion of the lower leg. It is usually a symptom of a greater problem, not a disease in itself. Foot drop is characterized by inability or impaired ability to raise the toes or raise the foot from the ankle (dorsiflexion). Foot drop may be temporary or permanent, depending on the extent of muscle weakness or paralysis and it can occur in one or both feet. In walking, the raised leg is slightly bent at the knee to prevent the foot from dragging along the ground.

Diplegia, when used singularly, refers to paralysis affecting symmetrical parts of the body. This is different from hemiplegia which refers to spasticity restricted to one side of the body, paraplegia which refers to paralysis restricted to the legs and hip, and quadriplegia which requires the involvement of all four limbs but not necessarily symmetrical. Diplegia is the most common cause of crippling in children, specifically in children with cerebral palsy. Other causes may be due to injury of the spinal cord. There is no set course of progression for people with diplegia. Symptoms may get worse but the neurological part does not change. The primary parts of the brain that are affected by diplegia are the ventricles, fluid filled compartments in the brain, and the wiring from the center of the brain to the cerebral cortex. There is also usually some degeneration of the cerebral neurons, as well as problems in the upper motor neuron system. The term diplegia can refer to any bodily area, such as the face, arms, or legs.

A selective dorsal rhizotomy (SDR), also known as a rhizotomy, dorsal rhizotomy, or a selective posterior rhizotomy, is a neurosurgical procedure that selectively cuts problematic nerve roots in the spinal cord. This procedure has been well-established in the literature as a surgical intervention and is used to relieve negative symptoms of neuromuscular conditions such as spastic diplegia and other forms of spastic cerebral palsy. The specific sensory nerves inducing spasticity are identified using electromyographic (EMG) stimulation and graded on a scale of 1 (mild) to 4. Abnormal nerve responses are isolated and cut, thereby reducing symptoms of spasticity.

<span class="mw-page-title-main">Calf (leg)</span> Back part of lower leg

The calf is the back portion of the lower leg in human anatomy. The muscles within the calf correspond to the posterior compartment of the leg. The two largest muscles within this compartment are known together as the calf muscle and attach to the heel via the Achilles tendon. Several other, smaller muscles attach to the knee, the ankle, and via long tendons to the toes.

<span class="mw-page-title-main">Orthotics</span> Medical specialty that focuses on the design and application of orthoses

Orthotics is a medical specialty that focuses on the design and application of orthoses, sometimes known as braces or calipers. An orthosis is "an externally applied device used to influence the structural and functional characteristics of the neuromuscular and skeletal systems." Orthotists are professionals who specialize in designing these braces.

<span class="mw-page-title-main">Locomotor effects of shoes</span>

Locomotor effects of shoes are the way in which the physical characteristics or components of shoes influence the locomotion neuromechanics of a person. Depending on the characteristics of the shoes, the effects are various, ranging from alteration in balance and posture, muscle activity of different muscles as measured by electromyography (EMG), and the impact force. There are many different types of shoes that exist, such as running, walking, loafers, high heels, sandals, slippers, work boots, dress shoes, and many more. However, a typical shoe will be composed of an insole, midsole, outsole, and heels, if any. In an unshod condition, where one is without any shoes, the locomotor effects are primarily observed in the heel strike patterns and resulting impact forces generated on the ground.

<span class="mw-page-title-main">Parkinsonian gait</span> Type of gait due to Parkinsons disease

Parkinsonian gait is the type of gait exhibited by patients with Parkinson's disease (PD). It is often described by people with Parkinson's as feeling like being stuck in place, when initiating a step or turning, and can increase the risk of falling. This disorder is caused by a deficiency of dopamine in the basal ganglia circuit leading to motor deficits. Gait is one of the most affected motor characteristics of this disorder although symptoms of Parkinson's disease are varied.

<span class="mw-page-title-main">Management of cerebral palsy</span>

Over time, the approach to cerebral palsy management has shifted away from narrow attempts to fix individual physical problems – such as spasticity in a particular limb – to making such treatments part of a larger goal of maximizing the person's independence and community engagement. Much of childhood therapy is aimed at improving gait and walking. Approximately 60% of people with CP are able to walk independently or with aids at adulthood. However, the evidence base for the effectiveness of intervention programs reflecting the philosophy of independence has not yet caught up: effective interventions for body structures and functions have a strong evidence base, but evidence is lacking for effective interventions targeted toward participation, environment, or personal factors. There is also no good evidence to show that an intervention that is effective at the body-specific level will result in an improvement at the activity level, or vice versa. Although such cross-over benefit might happen, not enough high-quality studies have been done to demonstrate it.

Children's feet are smaller than those of adults, not reaching full size until the ages of 13 in girls and 15 in boys. There are correspondingly small sizes of shoes for them. In poor populations and tropical countries, children commonly go barefoot.

A DAFO is a brand name for some lower extremity braces that provide thin, flexible, external support to the foot, ankle and/or lower leg. They have the particularity to fit firmly the ankle and correct concisely the foot deformity within special pressure points. It is stated to help in improving mobility and stability of the ankle joint on CP patients, evidence shows that immediate gross motor function improved with the use of DAFOs as well. Designed to help a patient maintain a functional position, a DAFO can improve stability for successful standing and walking.

<span class="mw-page-title-main">Spastic cerebral palsy</span> Cerebral palsy characterized by high muscle tone

Spastic cerebral palsy is the type of cerebral palsy characterized by spasticity or high muscle tone often resulting in stiff, jerky movements. Cases of spastic CP are further classified according to the part or parts of the body that are most affected. Such classifications include spastic diplegia, spastic hemiplegia, spastic quadriplegia, and in cases of single limb involvement, spastic monoplegia.

Neuromechanics of orthoses refers to how the human body interacts with orthoses. Millions of people in the U.S. suffer from stroke, multiple sclerosis, postpolio, spinal cord injuries, or various other ailments that benefit from the use of orthoses. Insofar as active orthoses and powered exoskeletons are concerned, the technology to build these devices is improving rapidly, but little research has been done on the human side of these human-machine interfaces.

<span class="mw-page-title-main">Diane Damiano</span> American biomedical scientist and physical therapist

Diane Louise Damiano is an American biomedical scientist and physical therapist specializing in physical medicine and rehabilitation approaches in children with cerebral palsy. She is chief of the functional and applied biomechanics section at the National Institutes of Health Clinical Center. Damiano has served as president of the Clinical Gait and Movement Analysis Society and the American Academy for Cerebral Palsy and Developmental Medicine.

References

  1. ↑ 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.
  2. ↑ "Toe Walking". Mayo Clinic. Archived from the original on 2007-06-03. Retrieved 2007-06-24.
  3. ↑ Babb A, Carlson WO (2008). "Idiopathic toe-walking". South Dakota Medicine. 61 (2): 53, 55–7. PMID   18432151.
  4. ↑ 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.
  5. 1 2 "Toe Walking". emedecine.com. Archived from the original on 2007-06-01. Retrieved 2007-06-07.
  6. ↑ "Equinus Deformity at Foot Associates of Central Texas, LLC". 2009. Archived from the original on 2013-12-08. Retrieved 2013-12-11.
  7. ↑ 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:10.1111/j.1469-8749.1999.tb00553.x. PMID   10619285.
  8. ↑ 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.
  9. ↑ Accardo PJ, Capute AJ. The Capute Scales: Cognitive Adaptive Test/Clinical Linguistic & Auditory Milestone Scale (CAT/CLAMS). Baltimore, MD: Paul H. Brookes Publishing Co; 2005
  10. ↑ Barkocy, Marybeth; Schilz, Jodi; Heimerl, Sandra; Chee, Madeleine; Valdez, Meghan; Redmond, Kelly (April 2021). "The Effectiveness of Serial Casting and Ankle Foot Orthoses in Treating Toe Walking in Children With Autism Spectrum Disorder". Pediatric Physical Therapy. 33 (2): 83–90. doi:10.1097/PEP.0000000000000784. PMID   33724238. S2CID   232242384.
  11. ↑ Shetreat-Klein, Maya; Shinnar, Shlomo; Rapin, Isabelle (February 2014). "Abnormalities of joint mobility and gait in children with autism spectrum disorders". Brain and Development. 36 (2): 91–96. doi:10.1016/j.braindev.2012.02.005. PMID   22401670. S2CID   27287327.
  12. ↑ Barkocy, Marybeth; Schilz, Jodi; Heimerl, Sandra; Chee, Madeleine; Valdez, Meghan; Redmond, Kelly (April 2021). "The Effectiveness of Serial Casting and Ankle Foot Orthoses in Treating Toe Walking in Children With Autism Spectrum Disorder". Pediatric Physical Therapy. 33 (2): 83–90. doi:10.1097/PEP.0000000000000784. PMID   33724238. S2CID   232242384.
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ "Votre enfant marche sur la pointe des pieds? Pas de quoi s'inquiéter". naitreetgrandir.com (in French). Retrieved 2023-07-20.
  16. ↑ 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.
  17. ↑ 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.
  18. ↑ 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.
  19. ↑ 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 of Child Neurology. 31 (7): 858–863. doi: 10.1177/0883073815624760 . PMID   26733505. S2CID   5526538.
  20. ↑ 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.
  21. ↑ Alvarez, Christine; De Vera, Mary; Beauchamp, Richard; Ward, Richard; Black, Alac (2007). "Classification of idiopathic toe walking based on gait analysis: development and application of the ITW severity classification". Gait & Posture. 26 (3): 428–435. doi:10.1016/j.gaitpost.2006.10.011. PMID   17161602.
  22. ↑ 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.
  23. ↑ 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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  24. ↑ 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.
  25. ↑ Sandu C, Burloiu CM, Barca DG, Magureanu SA, Craiu DC (2019). "Ketogenic Diet in Patients with GLUT1 Deficiency Syndrome". Maedica (Bucur). 14 (2): 93–97. doi:10.26574/maedica.2019.14.2.93 (inactive 31 January 2024). PMC   6709387 . PMID   31523287.{{cite journal}}: CS1 maint: DOI inactive as of January 2024 (link) CS1 maint: multiple names: authors list (link)
  26. ↑ "Toe Walking". orthoseek.com. Archived from the original on 2007-09-19. Retrieved 2007-06-07.
  27. ↑ "Toe Walking". mastersofpediatrics.com. Archived from the original on 2007-06-08. Retrieved 2007-06-24.
  28. 1 2 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.
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