Volume 3, Issue 5 - Midwest Orthopaedics at Rush

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Need Kicker Making Strides Controversy surrounds the treatment of idiopathic toe walking By Monica Kogan, MD When children begin walking, a toe-to-toe gait pattern is considered part of normal gait develop- ment. However, a toe-walking gait pattern that persists past the age of 2 is considered abnormal, depending on gait velocity 11 . There are many causes for persistent toe walking in children, including cerebral palsy, congenital contractures of the Achilles tendon, muscular dystrophy, and idiopathic toe walking (ITW). Diagnosis The diagnosis of ITW is one of exclusion and can be challenging. For example, children with ITW typically walk on their toes but are able to flatten their foot on request or when concentrating on their gait. It may be especially difficult to distinguish ITW from children with mild spastic diplegia 7-10 . Children with cerebral palsy begin walking at a later age, and children with ITW begin to walk at the appropriate time, 18 months. The etiology of ITW is not known. Some authors have suggested that ITW patients 20 Orthopaedic Excellence have congenitally short tendo Achilles 6 . Others have divided patients into habitual toe walkers or those with short tendo Achilles 4 . If left untreated, the natural progression of persistent toe walking places children at risk for falling 2 , developing limitations in ankle mobility, and structural abnormalities, such as persistent outward tibial torsion 3 . Treatment Much controversy exists around the treatment of ITW. The goal of any treatment is to provide normal function, but also important is limiting the impact on the child and family. Heel cord lengthening (either open or closed), serial casting, and stretching and physical therapy are treatment options. Nonsurgical Solutions Nonoperative management, such as serial casting to stretch the plantar flexors, is believed by some to be the optimal initial treatment 13 . Each week, the child goes to the physical therapist to have the ankle stretched and a new cast applied. This process goes on six weeks or longer. Brower et. al. 1 showed that children with ITW along with cerebral palsy who toe walk and were treated with serial casting showed improvement in dorsiflexion and toe walking. Griffin et. al. 5 performed a gait analysis comparing ITW with heel-toe walkers before and after serial casting; the analysis showed that serial casting increased the range of dorsiflexion and also changed the muscle synergy pattern from abnormal to normal. Tachdian 13 suggested passive stretching of the heel cords, gait training, and below-knee walking casts as the initial treatment of ITW, with surgery being reserved for patients more than 8 years of age who have failed to respond to nonoperative treatment. Stretching without casting is an option where the child undergoes weekly stretching by a physical therapist, followed by gait training. Surgical Solutions The reported failure rate of nonoperative treatment is significant, leading to the recommendation by others that surgical intervention be the primary treatment. Proponents argue that operative management
of either an open or percutaneous Achilles lengthening produces more consistent outcomes, with improved ankle dorsiflexion and greater parental satisfaction 11 . Stricker and Angulo 12 showed that children treated initially with surgical intervention had better results with respect to restoration of ankle dorsiflexion and parental satisfaction, and that cast and brace treatment offered little long-term improvement compared with untreated ITW. Hall et. al. 6 performed tendo Achilles lengthenings on a group of patients who showed no improvement after six months to two years of observation. They showed that, when treated surgically, the children exhibited normal passive and active dorsiflexion with a heel-toe gait pattern, except for occasional toe walking in older children. Both percutaneous and open techniques have been used for tendo Achilles lengthening. Patients are placed in below-the-knee weightbearing casts for four weeks and are allowed to bear weight immediately. During the four-week period, they participate in physical therapy for gait training. Since they have likely toe walked since ambulation began, patients need to be retrained to walk. Physical therapy should continue after the casts are removed, and it is beneficial that Bibliography 1. Brouwer B, davidson LK, Olney SJ. Serial casting in idiopathic toe-walkers and children with spastic cerebral palsy. J Pediatr orthop 2000;20:221- . 2. Caselli MA, Rzonca eC, Lue By. habitual toe walking: evaluation and approach to treatment. clin Podiatr Med surg 1 ; : - . . deLuca pA. the musculoskeletal management of children with cerebral palsy. Pediatr clin north am 1 ; :11 - 0. . furrer f, deonna t. persistent toe walking in children: a comprehensive clinical study of 2 cases. Helv Paediatr acta 1 2; : 01-1 . . Griffin p, Wheelhouse W, Shiavi R, Bass W. habitual younger children go to a center that has pediatric physical therapists. Conclusion ITW is a problem that is seen quite often. Both operative and nonoperative methods of treatment have been recommended, and each has its pros and cons. Serial casting is a lengthy process with the child attending physical therapy once a week If left untreated, persistent toe walking can lead to structural limitations and abnormalities in the hips, knees, ankles, and feet. To achieve similar force and movement levels as those required during heel-toe walking, toe walkers require greater activation of less commonly used muscles, weakening the quadriceps and other muscles and threatening joint stability. toe walkers: a clinical and electromyographic gait analysis. J Bone Joint surg [Am] 1 ; : -101. . hall Je, Salter RB, Bhalla SK. Congenital short tendo calcaneus. J Bone Joint surg [Br] 1 ; : - . . hicks R, durinick n, Gage JR. differentiation of idiopathic toe walking and cerebral palsy. J Pediatr orthop 1 ; :1 0- . . Katz MM, Mubarak SJ. hereditary tendo Achilles contractures. J Pediatr orthop 1 ; : 11- . . Rose J, Martin J, torburn L, et al. electromyographic differentiation of diplegic cerebral palsy from idiopathic toe walking: involuntary coactivation of the quadriceps and Diagnostics and Treatment for at least six weeks, followed by physical therapy after cast removal. This can be time consuming for both the patient and the parent or caregiver. Surgery as the initial treatment may be seen by some as aggressive, but the results have been more consistent. Often, parents or caregivers will try nonoperative measures first and opt for surgical intervention if no improvement is seen. Studies show that most often children end up requiring surgery. However, no damage is done by trying physical therapy first. If nothing else, parents or caregivers feel secure knowing that all options were exhausted before opting for surgery. Monica Kogan, MD, specializes in pediatric orthopaedics at Midwest Orthopaedics at Rush. A medical graduate from the University of Illinois College of Medicine in Chicago, Dr. Kogan completed a residency in orthopaedic surgery at Northwestern Memorial Hospital. A fellowship in pediatric orthopaedic surgery was completed at the Primary Children’s Medical Center in Salt Lake City, Utah, a renowned pediatric center serving five states in the intermountain region. gastrocnemius. J Pediatr orthop 1 ;1 : - 2. 10. Sala dA, Shulman Lh, Kennedy Rf, et al. Idiopathic toe walking: a review. dev Med child neuro 1 ; 1: - . 11. Statham L, Murray Mp. early walking patterns of normal children. clin orthop 1 1; : -2 . 12. Stricker SJ, Angulo JC. Idiopathic toe walking: a comparison of treatment methods. J Pediatr orthop 1 ;1 :2 - . 1 . tachdjian MO. the foot and leg. In: tachdjian MO, ed. Pediatric orthopaedics, vol. 2. philadelphia: Saunders: 1 2:1 - 0. Orthopaedic Excellence 21
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Volume 3, Issue 5 - Midwest Orthopaedics at Rush

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