In children diagnosed with idiopathic toe walking, is Physical Therapy and dynamic
splinting better than surgical intervention in restoring normal gait mechanics?
Erica Essex, PT Student | Jimmy Crick, PT Student
Background
• Idiopathic toe walking (ITW) is a toe-toe gait pattern that
persists after the age of 2 in a developmentally normal child. 1,2
• Also referred to as habitual toe-walking or congenital short
tendo calcaneus
• Normal occurrence in children with developing gait (< age 2)
• Theories of etiology include:
-Congenital shortening of tendo-calcaneus3
-Hereditary trait (autosomal dominant pattern of
inheritance) 3
-Mild spastic diplegia (with no neurological issues) 3
• ITW has been associated with:
-Family history of occurrence1,4
-Concurrent speech/language delays1,3
-Learning disabilities2,3
• ITW clinical presentation:
2,5
-Typical gait except bearing weight on forefoot
-PROM for dorsiflexion exceeds amount necessary for
normal gait 2,5
-Decreased extensibility of one or both triceps surea
muscles and/or heel cord 2,5
1,2,3,5
-Normal neurologic exam
Conservative Treatment
Conclusion
• Options include: Physical Therapy (PT), dynamic
splinting/serial casting, night splinting, AFO’s, and botulinum
toxin injections
• Physical Therapy includes: gait retraining, passive plantar
flexors stretching, dorsiflexors strengthening, and active
plantar flexor exercises 2,7,8
• With 6 weeks of serial casting and PT, increased DF range and
normal gait EMG restoration has been shown 9
• With 4 months of PT and night splinting, normal gait
restoration has been shown 7
• With median of 6 weeks of casting, dramatic improvements in
heel-toe gait have been shown 1
• With serial casting, exercises alone,
or a combination of both,
increased DF and heel-toe
gait pattern have been improved 10
• PT with dynamic splinting and surgery are equally effective in
normalizing gait in ITW’s
• Surgery may be more effective with a fixed equinas
contracture
• Greater risk associated with surgery
• Conservative treatment should be considered first
• Further research is needed to :
- determine any residual negative issues caused by
prolonged abnormal gait in cases who spontaneously
resolve
http://www.alimed.com/alimed-pediatric-classic-night-splint.html
Surgical Treatment
Peden S. Idiopathic Toe Walking. J. ICRU. 2009;9(2):NP.
http://chesapeakechildrenstherapycenter.wordpress.com/2013/08/26/toe-walking-and-physical-therapy/
• Surgical procedures for ITW include: 4,6
- Vulpius: Gastroc recession proximal to
Achilles
- Tendo-Achilles Lengthening: Gastroc and
Soleus lengthening
- Baumann: proximal Gastroc lengthening
- Strayer: Gastroc lengthening at
musculotendinous junction
• Surgery is recommended for:
- fixed equinas contractures 4,5,6
- non-responders to conservative
1,4
treatment
• Surgical outcomes are generally positive
• Primary risk: residual weakening of ankle
plantar flexors leading to a calcaneal gait
pattern 1,4
Clinical Relevance
• Early PT is important
• Dynamic splinting improves
outcomes with PT
• Gait can normalize spontaneously
• Potential future orthopedic problems:
6
- anterior pelvic tilt
-ER feet (theorized to be due to
either an ER tibia or ER femur
compensation)1,4,6
1
-hindfoot valgus
1,4,6
-equinas contracture
• May be an indicator of developmental problems - should
be referred for a developmental assessment and PT2,3
http://www.foot-pain-explained.com/toe_walking.html
References
1. Fox A, Deakin S. Serial casting in the treatment of idiopathic toe-walkers and review of the literature. Acta ….
2006;72(6):722–730. Available at:
2. Sala D a, Shulman LH, Kennedy RF, Grant a D, Chu ML. Idiopathic toe-walking: a review. Dev. Med. Child
Neurol. 1999;41(12):846–8.
3. Shulman LH, Sala D a, Chu ML, McCaul PR, Sandler BJ. Developmental implications of idiopathic toe walking.
J. Pediatr. 1997;130(4):541–6.
4. Peden S. Idiopathic Toe Walking. J. ICRU. 2009;9(2):NP.
5. Hirsch G, Wagner B. The natural history of idiopathic toe-walking: a long-term follow-up of fourteen
conservatively treated children. Acta Paediatr. 2004;(93):196–200.
6. McMulkin ML, Baird GO, Caskey PM, Ferguson RL. Comprehensive outcomes of surgically treated idiopathic
toe walkers. J. Pediatr. Orthop. 2006;26(5):606–11.
7. Lundequam P, Willis FB. Dynamic splinting home therapy for toe walking: a case report. Cases J. 2009;2:188.
8. Tachdjian M. The Child’s Foot. Philadelphia: WB Saunders; 1985.
9. Griffin PP, Wheelhouse WW, Shiavi R BW. Habitual Toe-Walkers. J. Bone Jt. Surg. 1977;59A:97–101.
10. Katz MM MS. Hereditary tendo Achillis contractures. J. Pediatr. Orthop. 1984;4:711–714.