Idiopathic Toe Walking: Difference between revisions
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== Introduction == | == Introduction == | ||
Idiopathic toe walking (ITW) is a diagnostic term used to describe a condition in otherwise healthy, ambulant children who present with a toe-toe gait. It is a diagnosis of exclusion, where no determinable pathology exists.<ref name=":1">· Le Cras S, Bouck J, Brausch S, Taylor-Haas A. Evidence-based Clinical Care Guideline for Management of Idiopathic Toe Walking. Cincinnati Children's Hospital Medical Center. Guideline 040, pages 1-17 (2011).</ref> | |||
An | Toe walking itself occurs in the absence of heel strike during initial contact. There is also the absence of full contact of the foot during stance phase in the gait cycle. Weight is kept primarily on the forefoot, often on the metatarsal heads.<ref name=":3">Van Kuijk AA, Kosters R, Vugts M, Geurts AC. Treatment for idiopathic toe walking: a systematic review of the literature. Journal of rehabilitation medicine. 2014 Nov 1;46(10):945-57.</ref> <ref name=":0">Dilger N. Idiopathic Toe Walking: A diagnosis of Exclusion or a Developmental Marker. Los Angeles, California. Footprints Pediatric Physical Therapy. 2005</ref> | ||
An operational definition given by Dilger <ref name=":0" /> is “an equinus gait, initially without fixed contractures, with passive dorsiflexion range of motion (ROM) of the plantar flexor musculature to dorsiflex to at least neutral (0°) with the subtalar joint inverted and with the knee extended." | |||
ITW is also known as toe walking, habitual toe walking, and congenital short tendo calcaneus. <ref name=":1" /> | |||
ITW may initially present in pre-walking skill acquisition, the start of independent walking, or within 6 months of the initiation of independent walking. <ref name=":1" /> | |||
While some patients who present with ITW do so 100% during gait, some are able to spontaneously move to a heel-toe gait pattern. <ref name=":1" /> | |||
== Epidemiology == | |||
Reports of the incidence of ITW vary considerably. From 7%-24% <ref>Sobel E, Caselli MA, Velez Z. Effect of persistent toe walking on ankle equinus. Analysis of 60 idiopathic toe walkers. Journal of the American Podiatric Medical Association. 1997 Jan;87(1):17-22.</ref>to between 2% - 5%<ref name=":1" /><ref name=":2">Lorentzen J, Willerslev‐Olsen M, Hüche Larsen H, Svane C, Forman C, Frisk R, Farmer SF, Kersting U, Nielsen JB. Feedforward neural control of toe walking in humans. The Journal of physiology. 2018 Jun;596(11):2159-72.</ref>This is seen in part because much of the literature views toe-walking as part of normal gait development in children under the age of 2 years<ref name=":3" /> | |||
== Aetiology == | == Aetiology == | ||
Children presenting with ITW also often present with ankle equinus and/ or limited range in the ankle plantarflexors. Initially, this was thought to be a causational factor, but in more recent studies it is thought to be more a ''result'' of ITW. <ref name=":3" /> | |||
When it was initially described in the 1960's a genetically inherited trait was attributed to its development.<ref name=":0" /> | |||
Another, more recent school of thought is that ITW is a product of hyperreactivity of reflexes; an adaption to sensory feedback.<ref name=":2" /> It has been hypothesized that a delay in maturation of the corticospinal tract results in a lack of inhibition of the stretch reflexes and subsequent increased deep tendon reflexes. The literature review performed by Lorentzen et al.<ref name=":2" /> found that corticospinal pathways are active and important at the level of the presynapse of motor neurons of the ankle plantar flexors. | |||
In regard to the feedforward mechanisms, dysregulation in sensory integration has been hypothesized. Sensory integration is "the registration and modulation of sensory input for the execution of motor output". <ref name=":0" />(p.4) Examples of disrupted regulation can be viewed with hypertonia, leading to decreased proprioceptive and vestibular input, and thus altered biomechanics, seeking further input through the metatarsal joints. On the opposite end of the spectrum, tactile defensiveness resulting from the input which is perceived as too much or noxious could also result in toe walking gait.<ref name=":0" /> | |||
== Pathophysiology == | == Pathophysiology == | ||
While the aeitiology of ITW remains unclear, there is consensus that as the child progresses in age, certain biomechanical changes occur. This includes shortened tendon achilles, as well as contractures of the foot and ankle joints.<ref name=": | While the aeitiology of ITW remains unclear, there is consensus that as the child progresses in age, certain biomechanical changes occur. This includes shortened tendon achilles, as well as contractures of the foot and ankle joints. This is more prominent in older children presenting with ITW <ref name=":0" /><ref name=":1" /><ref name=":3" /> | ||
Muscle biopsies done also indicate a higher percentage of type I muscle fibres in the gastrocnemius muscle than what would be expected.<ref name=":0" /> <ref name=":2" /> | |||
== | == Differential Diagnosis == | ||
Diagnosis is one of exclusion. Hence the differential diagnosis is used. The following is a list of diagnoses to rule out:<ref name=":3" /><ref name=":4">Caserta AJ, Pacey V, Fahey MC, Gray K, Engelbert RH, Williams CM. Interventions for idiopathic toe walking. Cochrane Database of Systematic Reviews. 2019(10).</ref> | |||
* Neuromotor disease | |||
* Neuromuscular disease | |||
* Cerebral palsy | |||
* Spina Bifida | |||
* Tethered cord syndrome | |||
* Spinal dysraphism | |||
* Spinal cord tumour | |||
== Diagnostic procedures == | == Diagnostic procedures == | ||
Despite having no known cause, studies have shown persistent gait kinematic and EMG abnormalities, even when attempting to heel-toe walk. <ref name=":1" /> In studies done with EMG, it was ascertained that the gastrocnemius and tibialis anterior (TA) were out of phase, or imbalanced. Early and predominant firing was noted in the gastrocnemius muscles during the swing and stance phase. In addition, low amplitude of TA was noted during both stance and swing. These results showed some evidence in the ability to diagnose ITW through EMG<ref name=":1" /> <ref name=":3" />Caution must be used when considering this as a form of diagnosis. In the study performed by Dilger<ref name=":0" />showed similar firing patterns to that of children diagnosed with mild cerebral palsy. | |||
== Prognosis == | == Prognosis == | ||
== Management == | == Management == | ||
Initial management is conservative, with some of these treatment regimes including Botulism Toxin A (BTX). Surgical intervention is usually undertaken when conservative measures have been exhausted.<ref name=":1" /> <ref name=":3" /><ref name=":4" /> | |||
== | == Conservative management == | ||
=== Conservative management === | === Conservative management === | ||
Revision as of 20:25, 25 April 2022
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Introduction[edit | edit source]
Idiopathic toe walking (ITW) is a diagnostic term used to describe a condition in otherwise healthy, ambulant children who present with a toe-toe gait. It is a diagnosis of exclusion, where no determinable pathology exists.[1]
Toe walking itself occurs in the absence of heel strike during initial contact. There is also the absence of full contact of the foot during stance phase in the gait cycle. Weight is kept primarily on the forefoot, often on the metatarsal heads.[2] [3]
An operational definition given by Dilger [3] is “an equinus gait, initially without fixed contractures, with passive dorsiflexion range of motion (ROM) of the plantar flexor musculature to dorsiflex to at least neutral (0°) with the subtalar joint inverted and with the knee extended."
ITW is also known as toe walking, habitual toe walking, and congenital short tendo calcaneus. [1]
ITW may initially present in pre-walking skill acquisition, the start of independent walking, or within 6 months of the initiation of independent walking. [1]
While some patients who present with ITW do so 100% during gait, some are able to spontaneously move to a heel-toe gait pattern. [1]
Epidemiology[edit | edit source]
Reports of the incidence of ITW vary considerably. From 7%-24% [4]to between 2% - 5%[1][5]This is seen in part because much of the literature views toe-walking as part of normal gait development in children under the age of 2 years[2]
Aetiology[edit | edit source]
Children presenting with ITW also often present with ankle equinus and/ or limited range in the ankle plantarflexors. Initially, this was thought to be a causational factor, but in more recent studies it is thought to be more a result of ITW. [2]
When it was initially described in the 1960's a genetically inherited trait was attributed to its development.[3]
Another, more recent school of thought is that ITW is a product of hyperreactivity of reflexes; an adaption to sensory feedback.[5] It has been hypothesized that a delay in maturation of the corticospinal tract results in a lack of inhibition of the stretch reflexes and subsequent increased deep tendon reflexes. The literature review performed by Lorentzen et al.[5] found that corticospinal pathways are active and important at the level of the presynapse of motor neurons of the ankle plantar flexors.
In regard to the feedforward mechanisms, dysregulation in sensory integration has been hypothesized. Sensory integration is "the registration and modulation of sensory input for the execution of motor output". [3](p.4) Examples of disrupted regulation can be viewed with hypertonia, leading to decreased proprioceptive and vestibular input, and thus altered biomechanics, seeking further input through the metatarsal joints. On the opposite end of the spectrum, tactile defensiveness resulting from the input which is perceived as too much or noxious could also result in toe walking gait.[3]
Pathophysiology[edit | edit source]
While the aeitiology of ITW remains unclear, there is consensus that as the child progresses in age, certain biomechanical changes occur. This includes shortened tendon achilles, as well as contractures of the foot and ankle joints. This is more prominent in older children presenting with ITW [3][1][2]
Muscle biopsies done also indicate a higher percentage of type I muscle fibres in the gastrocnemius muscle than what would be expected.[3] [5]
Differential Diagnosis[edit | edit source]
Diagnosis is one of exclusion. Hence the differential diagnosis is used. The following is a list of diagnoses to rule out:[2][6]
- Neuromotor disease
- Neuromuscular disease
- Cerebral palsy
- Spina Bifida
- Tethered cord syndrome
- Spinal dysraphism
- Spinal cord tumour
Diagnostic procedures[edit | edit source]
Despite having no known cause, studies have shown persistent gait kinematic and EMG abnormalities, even when attempting to heel-toe walk. [1] In studies done with EMG, it was ascertained that the gastrocnemius and tibialis anterior (TA) were out of phase, or imbalanced. Early and predominant firing was noted in the gastrocnemius muscles during the swing and stance phase. In addition, low amplitude of TA was noted during both stance and swing. These results showed some evidence in the ability to diagnose ITW through EMG[1] [2]Caution must be used when considering this as a form of diagnosis. In the study performed by Dilger[3]showed similar firing patterns to that of children diagnosed with mild cerebral palsy.
Prognosis[edit | edit source]
Management[edit | edit source]
Initial management is conservative, with some of these treatment regimes including Botulism Toxin A (BTX). Surgical intervention is usually undertaken when conservative measures have been exhausted.[1] [2][6]
Conservative management[edit | edit source]
Conservative management[edit | edit source]
Physiotherapy management[edit | edit source]
Additional read[edit | edit source]
Resources[edit | edit source]
- bulleted list
- x
or
- numbered list
- x
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 · Le Cras S, Bouck J, Brausch S, Taylor-Haas A. Evidence-based Clinical Care Guideline for Management of Idiopathic Toe Walking. Cincinnati Children's Hospital Medical Center. Guideline 040, pages 1-17 (2011).
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Van Kuijk AA, Kosters R, Vugts M, Geurts AC. Treatment for idiopathic toe walking: a systematic review of the literature. Journal of rehabilitation medicine. 2014 Nov 1;46(10):945-57.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Dilger N. Idiopathic Toe Walking: A diagnosis of Exclusion or a Developmental Marker. Los Angeles, California. Footprints Pediatric Physical Therapy. 2005
- ↑ Sobel E, Caselli MA, Velez Z. Effect of persistent toe walking on ankle equinus. Analysis of 60 idiopathic toe walkers. Journal of the American Podiatric Medical Association. 1997 Jan;87(1):17-22.
- ↑ 5.0 5.1 5.2 5.3 Lorentzen J, Willerslev‐Olsen M, Hüche Larsen H, Svane C, Forman C, Frisk R, Farmer SF, Kersting U, Nielsen JB. Feedforward neural control of toe walking in humans. The Journal of physiology. 2018 Jun;596(11):2159-72.
- ↑ 6.0 6.1 Caserta AJ, Pacey V, Fahey MC, Gray K, Engelbert RH, Williams CM. Interventions for idiopathic toe walking. Cochrane Database of Systematic Reviews. 2019(10).
