Idiopathic Toe Walking

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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.

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.

An operational definition given by Dilger  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.

ITW may initially present in pre-walking skill acquisition, the start of independent walking, or within 6 months of the initiation of independent walking.

While some patients who present with ITW do so 100% during gait, some are able to spontaneously move to a heel-toe gait pattern.

Epidemiology

Reports of the incidence of ITW vary considerably. From 7%-24% to between 2% - 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

Aetiology

Equinus foot/ Forefoot weight bearing

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.

When it was initially described in the 1960's a genetically inherited trait was attributed to its development.

Another, more recent school of thought is that ITW is a product of hyperreactivity of reflexes; an adaption to sensory feedback. 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. 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". ^(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.

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. This is more prominent in older children presenting with ITW

Muscle biopsies done also indicate a higher percentage of type I muscle fibres in the gastrocnemius muscle than what would be expected.

Differential Diagnosis

Diagnosis is one of exclusion. Hence the differential diagnosis is used. The following is a list of diagnoses to rule out:

• Neuromotor disease
• Neuromuscular disease
• Cerebral palsy
• Spina Bifida
• Tethered cord syndrome
• Spinal dysraphism
• Spinal cord tumour

Diagnostic procedures

Despite having no known cause, studies have shown persistent gait kinematic and EMG abnormalities, even when attempting to heel-toe walk. 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 Caution must be used when considering this as a form of diagnosis. In the study performed by Dilgershowed similar firing patterns to that of children diagnosed with mild cerebral palsy.

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.

Conservative management

Conservative treatment can include the following:

• Serial casting
• Orthotics
• Footwear
• Auditory feedback
• Physiotherapy
• BTX
  • In a study performed in 2004 by Brunt et al., cited in Van Kuijk , BTX was used to treat triceps surae activity. With EMG as assessment, the activity of the muscle group was brought more closely to resemble normal activity immediately after treatment and at 1-year follow-up. Reports from a Cochrane review found that BTX had some success when done together with other conservative interventions including casting and footwear. Intervention in these studies was considered successful when toe walking was performed less than 50% of the time walking.

Surgical management

Surgical interventions described in the literature include:

• Vulpius procedure (gastrocneuius recessioin surgery)
• Tendon archillies lengthening. In a systematic review of this procedure an increased popliteal angle was noted, however, there was no real change to the hip and knee alignment of individuals after 1 year follow-up. The hips still displaying external rotation and knee tibial tortion.
• Open achillies tendon lengthening via a Z-lengthening or slide technique
• Baker’s gastrocnemius-soleus lengthening.

Side effects to surgical management noted in Caserta et al. as well as Van Kuijk et al. included excessive ankle dorsiflexion after tendon archilies lengthening.

Physiotherapy management

A physiotherapist's role in the management of ITW is multidimensional and includes the following.

• Hands-on therapy
  • Active and passive range exercises, emphasis on the ankles.
  • Strength training
  • Gait training
  • Home exercise program prescription

• In addition to the above, the physiotherapist will also be involved in footwear, casting and orthotic intervention. Whether this is again a hands-on aspect or on a consultative level.

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