Idiopathic Toe Research Articles

Idiopathic toe walkers: Conservative or surgical treatments?

Idiopathic toe walkers: Conservative or surgical treatments?

Gut Microbiome Dysbiosis as a Potential Risk Factor for Idiopathic Toe-Walking in Children: A Review.

Idiopathic toe walking (ITW) occurs in about 5% of children. Orthopedic treatment of ITW is complicated by the lack of a known etiology. Only half of the conservative and surgical methods of treatment give a stable positive result of normalizing gait. Available data indicate that the disease is heterogeneous and multifactorial. Recently, some children with ITW have been found to have genetic variants of mutations that can lead to the development of toe walking. At the same time, some children show sensorimotor impairment, but these studies are very limited. Sensorimotor dysfunction could potentially arise from an imbalanced production of neurotransmitters that play a crucial role in motor control. Using the data obtained in the studies of several pathologies manifested by the association of sensory-motor dysfunction and intestinal dysbiosis, we attempt to substantiate the notion that malfunction of neurotransmitter production is caused by the imbalance of gut microbiota metabolites as a result of dysbiosis. This review delves into the exciting possibility of a connection between variations in the microbiome and ITW. The purpose of this review is to establish a strong theoretical foundation and highlight the benefits of further exploring the possible connection between alterations in the microbiome and TW for further studies of ITW etiology.

A Pilot Study of Idiopathic Toe Walking: Measures and Outcomes

This pilot study sought to determine the feasibility of quantifying sensory processing, postural control, motor skill development and participation in daily life in children with idiopathic toe walking (ITW) compared to children without ITW. A nonrandomized, prospective case-control design was employed. Twenty participants were recruited. Computerized weight bearing and postural control data was successfully collected. Differences were found in forefoot/rearfoot weight bearing, balance, sensory-motor abilities and parent reported participation challenges. Sensory processing results were inconclusive. Findings can inform standardized assessment and treatment of ITW.

Some children with idiopathic toe walking display sensory processing difficulties but not all: A systematic review.

Idiopathic toe walking (ITW) is a diagnosis for children who toe walk without another diagnosis known to cause toe walking. Recent research has suggested that children with ITW may have mild motor planning challenges and sensory processing differences. The primary aim of this systematic review was to determine whether children diagnosed with ITW have differences in their sensory processing compared to typically developing children. Secondary aims included determining how sensory processing was assessed in this population and documenting the broad clinometric and psychometric properties of any assessment tools. MEDLINE, CINAHL, AMED and Embase were searched for relevant literature in English. Studies were eligible for inclusion if they described children aged 3 and 18 with idiopathic toe walking and reported a sensory processing domain. Twelve articles met the inclusion criteria; however, only two papers included data permitting meta-analysis. Meta-analyses of vibration perception threshold using a random effect model were not significant (p = 0.31). Other data were synthesised by narrative and showed a high heterogeneity across multiple sensory processing domains. This study highlights that despite children with ITW often conceptualised as possessing sensory processing challenges, there is little evidence supporting this theory. Further research on sensory processing in children with this gait pattern is necessary.

Stepping Beyond Efficacy: Understanding the User Experience of Wearables for Children with Idiopathic Toe Walking in the Natural Setting

Idiopathic Toe Walking is an atypical gait pattern that results in limited mobility, pain, and higher risk of falling. Current therapeutic interventions lack the ability to be implemented outside the clinic or lab. Beyond this, it is unclear if gait analysis and real-time feedback is technologically feasible to attain within a user's natural environment. In our research we aimed to understand the child and parent participants’ experience of an innovative wearable system. We surveyed children and parents after the deployment of a functional prototype with real time vibrotactile feedback for awareness of toe walking via a shoe insert paired with a smartphone for visual feedback. Findings revealed insights into design considerations for wearable technologies for children. Factors such as comfort of using the system (physically and psychologically), child's perception and response to the vibrotactile feedback, and children and parents’ perception of reduced fall risk, pain, and stigma are discussed.

NGS-Panel Diagnosis Developed for the Differential Diagnosis of Idiopathic Toe Walking and Its Application for the Investigation of Possible Genetic Causes for the Gait Anomaly.

Idiopathic toe walking (ITW) describes a condition affecting approximately 4.5% of children. Toe walking is an accompanying symptom for many hereditary disorders. This retrospective study uses next-generation sequencing-panel-diagnosis to investigate the feasibility of genetic testing to research the possible genetic causes of ITW and for differential diagnosis. Data were taken from our inhouse database, the minimum age for participants was 3 years. Underlying neurological or orthopaedic conditions were tested for and ruled out prior to diagnosing ITW. Patients, who experienced complications before, during or immediately after birth, children with autism, and patients toe walking less than 50% of the time were excluded. Eighty-nine patients were included in the study, in which 66 (74.2%) patients were boys and 23 (25.8%) girls. Mean age at testing was 7.7 years (range: 3-17 years). Fifteen of the 89 patients included in the study (16.9%) had a genetic variant identified as likely pathogenic or pathogenic by the genetics laboratory. Additionally, we found 129 variants of uncertain significance. About 65.2% of patients showed a pes cavus foot deformity, 27% of patients reportedly had at least one relative who also displayed the gait anomaly, and 37.1% had problems with their speech development. Despite the limitations of the sample size and the scope of our genetic testing targets, our results indicate that research into the genetic causes of ITW could better our understanding of the causes of ITW in otherwise healthy children, to help develop novel methods to detect serious conditions early. ITW could be an early onset symptom for further hereditary conditions.

Ankle Kinematics Characterization in Children with Idiopathic Toe Walking: Does the Foot Model Change the Clinical Evaluation?

Idiopathic toe walking (ITW) is a gait deviation characterized by forefoot contact with the ground, sometimes observed in children, that alters ankle kinematics, possibly leading to health-related issues. When studying foot and ankle gait deviations, the adoption of a single-segment foot model entails a significant simplification of foot and ankle movement, and thus may potentially mask some important foot dynamics. Differences in ankle kinematics between single- (conventional gait model, PiG, or Davis) and multi-segment (Oxford foot model, OFM) foot models were investigated in children with ITW. Fourteen participants were enrolled in the study and underwent instrumented gait analysis. Children were asked to walk barefoot and while wearing a foot orthosis that modified the ankle movement pattern toward a more physiological one without blocking foot intrinsic motion. ITW gait abnormalities, e.g., the absence of heel rocker and the presence of anticipated forefoot rocker, were found/not found according to the foot model. Walking conditions significantly interacted with the foot model effect. Finally, the different characterization of gait abnormalities led to a different classification of ITW, with a possible impact on the clinical evaluation. Due to its closer adhesion to ankle anatomy and to its sensitivity to ITW peculiarities, OFM may be preferable for instrumented gait analysis in this population.

Does use of ankle foot orthoses affect the dynamic motor control index during walking in cerebral palsy and idiopathic toe walking populations?

BackgroundThe dynamic motor control (walk-DMC) index during walking is a measure of the complexity of muscle activation pattern. Ankle Foot Orthoses (AFO) are frequently used to improve the gait of children with Cerebral Palsy (CP) and Idiopathic Toe Walking (ITW). The purpose of this study was to assess the change in walk-DMC index secondary to AFO use. Research QuestionDoes the change in walk-DMC reflect the change in walking kinematics with the use of AFO. MethodsIndividuals with diagnosis of CP or ITW with gait analysis data available for barefoot and AFO condition were retrospectively identified. For each individual, the walk-DMC index, Gait Deviation Index (GDI) and Gait Variable Scores (GVS) of knee and ankle kinematics were computed for BF and AFO conditions. Paired t-tests were used to compare key variables between BF and AFO conditions. Multi-variate stepwise regression analysis was performed to identify variables that may predict the increase in walk-DMC between BF and AFO condition. Results253 individuals were included in the study. For CP individuals (n = 208), statistically significant but quantitatively minimal improvement was observed in walk-DMC (1 ± 9), GDI (2 ± 9) and ankle GVS (2 ± 7). For ITW individuals (n = 45), larger improvements were observed in walk-DMC (11 ± 13), GDI (9 ± 11) and ankle GVS (6 ± 7).Diagnosis of ITW, use of Solid-AFO and Posterior Leaf Spring-AFO were the significant predictor of increase in walk-DMC with AFO. Higher ankle GVS at BF condition (larger deviation from TD) led to larger increase in walk-DMC. Higher knee GVS (larger deviation from TD) led to smaller increase in walk-DMC. SignificanceUse of AFO can lead to improvement in walking kinematics that is reflected in increase in walk-DMC with AFO compared to BF for ITW individuals. The change in kinematics and walk-DMC with use of AFO was minimal for CP individuals.

Children’s orthopaedics

The February 2023 Children’s orthopaedics Roundup360 looks at: Trends in management of paediatric distal radius buckle fractures; Pelvic osteotomy in patients with previous sacral-alar-iliac fixation; Sacral-alar-iliac fixation in patients with previous pelvic osteotomy; Idiopathic toe walking: an update on natural history, diagnosis, and treatment; A prediction model for treatment decisions in distal radial physeal injuries: a multicentre retrospective study; Angular deformities after percutaneous epiphysiodesis for leg length discrepancy; MRI assessment of anterior coverage is predictive of future radiological coverage; Predictive scoring for recurrent patellar instability after a first-time patellar dislocation.

Impact of Gait Events Identification through Wearable Inertial Sensors on Clinical Gait Analysis of Children with Idiopathic Toe Walking

Idiopathic toe walking (ITW) is a gait deviation characterized by forefoot contact with the ground and excessive ankle plantarflexion over the entire gait cycle observed in otherwise-typical developing children. The clinical evaluation of ITW is usually performed using optoelectronic systems analyzing the sagittal component of ankle kinematics and kinetics. However, in standardized laboratory contexts, these children can adopt a typical walking pattern instead of a toe walk, thus hindering the laboratory-based clinical evaluation. With these premises, measuring gait in a more ecological environment may be crucial in this population. As a first step towards adopting wearable clinical protocols embedding magneto-inertial sensors and pressure insoles, this study analyzed the performance of three algorithms for gait events identification based on shank and/or foot sensors. Foot strike and foot off were estimated from gait measurements taken from children with ITW walking barefoot and while wearing a foot orthosis. Although no single algorithm stands out as best from all perspectives, preferable algorithms were devised for event identification, temporal parameters estimate and heel and forefoot rocker identification, depending on the barefoot/shoed condition. Errors more often led to an erroneous characterization of the heel rocker, especially in shoed condition. The ITW gait specificity may cause errors in the identification of the foot strike which, in turn, influences the characterization of the heel rocker and, therefore, of the pathologic ITW behavior.

Comparative Study between Percutaneous Elongation and Z- Lengthening of Tight Achilles Tendon in Idiopathic Toe Walking Children

Comparative Study between Percutaneous Elongation and Z- Lengthening of Tight Achilles Tendon in Idiopathic Toe Walking Children

Dense & Attention Convolutional Neural Networks for Toe Walking Recognition.

Idiopathic toe walking (ITW) is a gait disorder where children's initial contacts show limited or no heel touch during the gait cycle. Toe walking can lead to poor balance, increased risk of falling or tripping, leg pain, and stunted growth in children. Early detection and identification can facilitate targeted interventions for children diagnosed with ITW. This study proposes a new one-dimensional (1D) Dense & Attention convolutional network architecture, which is termed as the DANet, to detect idiopathic toe walking. The dense block is integrated into the network to maximize information transfer and avoid missed features. Further, the attention modules are incorporated into the network to highlight useful features while suppressing unwanted noises. Also, the Focal Loss function is enhanced to alleviate the imbalance sample issue. The proposed approach outperforms other methods and obtains a superior performance. It achieves a test recall of 88.91% for recognizing idiopathic toe walking on the local dataset collected from real-world experimental scenarios. To ensure the scalability and generalizability of the proposed approach, the algorithm is further validated through the publicly available datasets, and the proposed approach achieves an average precision, recall, and F1-Score of 89.34%, 91.50%, and 92.04%, respectively. Experimental results present a competitive performance and demonstrate the validity and feasibility of the proposed approach.

IncobotulinumtoxinA Injection for Treating Children with Idiopathic Toe Walking: A Retrospective Efficacy and Safety Study.

There is no gold-standard treatment for idiopathic toe walking (ITW). Some previous evidence suggested that botulinum neurotoxin-A injection might improve ITW. This is a single-center retrospective study on children with ITW treated with incobotulinumtoxinA injection in the gastrocnemius medialis/lateralis muscles. We screened the charts of 97 ITW children treated with incobotulinumtoxinA (January 2019-December 2021), and the data of 28 of them, who satisfied the inclusion/exclusion criteria, were analyzed. The maximal passive ankle dorsiflexion (knee extended) was assessed at three time points, i.e., immediately before incobotulinumtoxinA injection (T0), after incobotulinumtoxinA injection during the timeframe of its effect (T1), and at follow-up, when the effect was expected to disappear (T2). The maximal passive ankle dorsiflexion was improved by incobotulinumtoxinA injection, and the effect lasted up to 6 months in some children. No adverse effects were reported to incobotulinumtoxinA injections. The treatment with incobotulinumtoxinA might improve the maximal passive ankle dorsiflexion and is safe and well-tolerated in ITW with a longer-than-expected effect in comparison to cerebral palsy. These results may offer ground to future randomized controlled trials and studies assessing the effect of BoNT-A in combination with other non-invasive approaches and exercise programs in children with ITW.

Development of the Idiopathic Toe Walking Outcome (iTWO) proforma: A modified delphi study and online parent survey for measurement consensus

BackgroundIdiopathic toe walking (ITW) is an exclusionary diagnosis given when children toe walk without a medical reason. Treatment effectiveness studies rarely collect data other than ankle range of motion or presence of toe walking. Research questionTo develop a set of outcome measures identified by health professionals for use when providing treatment with children who have ITW, to understand if parents agreed with this set, and if parents believed they could perform these measures in clinician absence. MethodsStudy 1 developed consensus and agreement on outcome measures for children receiving treatment for ITW through the modified Delphi technique with 10 expert health professionals. Parents of children who toe walked were invited to participate in an online survey for the second study, in which they were asked to rate the importance of these measures and if they believed they may be able to collect the data about their child without the health professional being present. ResultsTen health professionals developed nine questions and assessments through consensus and agreement over the three rounds. There were 34 parents providing information about satisfaction with toe walking assessments and treatments. Of these, 27 provide detailed responses about the outcome questions and assessments. The majority (91 % of 24 parents) in support of the outcome measures identified by experts. Parents expressed a willingness to self-complete questions or be taught assessments to monitor their child’s progress. SignificanceUse of these clinically based measures may enable consistent data collection regardless of the setting and provide the foundation for large data pooling in future treatment research.

Exploration of physiotherapists’ use of motor control strategies for the treatment of idiopathic toe walking in children: a qualitative study

ObjectivesTo explore how motor control interventions are conceptualised during treatment of children with idiopathic toe walking (ITW) by physiotherapists in Australia and USA.DesignA thematic content framework qualitative design was used...

Idiopathic toe walking can be reduced by more physical activity and less screen time

Idiopathic toe walking can be reduced by more physical activity and less screen time

Adherence to serial casting protocols for idiopathic toe walking: A quality improvement initiative.

This initiative aimed to assess adherence to Scottish Rite for Children's serial casting protocol for children with idiopathic toe walking (ITW), factors related to adherence, and outcomes after education regarding the protocol. 60 patients aged 7.1±2.7 years who completed serial casting were examined at baseline phase (n = 30) and post-education phase (n = 30). Protocols include weekly serial casting for 4 to 6 weeks to achieve 10° of ankle dorsiflexion (ADF) passive range of motion (PROM) with knees extended (KE), assessing the foot posture index (FPI-6) and single leg stance (SLS). Baseline phase evaluated adherence to protocols. Education phase evaluated factors related to adherence and education regarding serial casting findings. Post-education phase evaluated the impact of the education phase. Serial casting averaged 4.8±1.5 weeks (n = 60). ADF PROM was measured with 100% adherence. ADF PROM KE averaged -10.7° pre-cast and significantly improved to +6.5° post-cast (n = 60), and it significantly improved post-cast post-education (p = 0.04). FPI-6 and SLS adherence significantly improved post-cast post-education. FPI-6 total score averaged +5.3 at baseline and +5.8 post-cast (n = 35). Education of staff in serial casting protocols improved adherence and patient outcomes. Patients with ITW and ADF PROM KE -10° benefit from serial casting to improve PROM and to allow for orthotic use post-casting.

Two-point discrimination responses in children with idiopathic toe walking: A feasibility fMRI study.

Idiopathic toe walking (ITW) is a diagnosis given to children who walk with an absence or limitation of heel strike in the contact phase of the gait cycle, that are otherwise typically developing. There is emerging evidence that this gait pattern may occur in children who experience tactile sensory processing challenges. This feasibility study aimed to determine if children were able to respond to a sensory stimulus during a fMRI. Children aged between 8-16 years of age, with and without idiopathic toe walking were recruited from general public advertising. Participants were required to perform a two-point discrimination test (task block) and press a button without being tested (control block) during an fMRI using a standard block design. Activation differences were examined in the left frontal pole, left supramarginal gyrus, left parahippocampal gyrus, left paracingulate gyrus and the right superior temporal. Five children were in the typically developing (TD) group and three were in the ITW group. There were between-group activation differences in the decision-making block compared to the control block in the left frontal lobe, parahippocampal gyrus and the right superior temporal gyrus. There was greater variation in activation in the left supramarginal gyrus and the left paracingulate gyrus in the ITW group compared to the typically developing group. Based on this study a future sample size of 15 children per group will be required to detect an adequate effect across chosen regions of interest Conducting fMRI using two-point discrimination testing on this population is feasible. Further research is required with larger population sizes to determine if brain activation patterns during the sensory input decision-making process are different in this population.

Effects of wearing a foot orthosis on ankle function in children with idiopathic toe walking during gait

BackgroundIdiopathic toe walking (ITW) is a gait deviation characterized by forefoot contact with the ground, possibly enhancing the risk of falling and causing Achilles’ tendon shortening and psychological discomfort. Between possible treatments, foot orthosis may limit ITW when worn. With these premises, the effects of a novel foot orthosis (A.Dyn.O.®) on ankle function were analyzed in children with ITW during gait. MethodsTwenty-one children were recruited in the study after ITW diagnosis. At follow-up assessment after a habituation period of at least two weeks, participants walked in barefoot condition and while wearing A.Dyn.O.®. Kinetics and kinematics were derived from a multi-segment foot model using an optoelectronic system. Gait spatiotemporal parameters, ankle kinetic and kinematic and rockers timing were analyzed. Lastly, ITW severity was classified according to Alvarez classification. Differences between conditions were verified with paired t-test. Statistical parametric mapping was used to evaluate differences in the entire kinematic and kinetic waveforms. FindingsWearing A.Dyn.O.®, step cadence was reduced, step length, stance phase and stride duration increased; physiological heel rocker was present, thus postponing the timing of ankle and forefoot rockers; ankle dorsiflexion angular excursion, range of motion, maximal dorsiflexor and plantarflexor moments together with maximal power absorption and production were all amplified. InterpretationWhile wearing it, A.Dyn.O.® limited gait deviations typical of ITW and improved ITW severity classification for most of the participants. These findings suggest that the use of A.Dyn.O.® may assist ITW treatment, preventing children from toe walking and thus limiting its side effects.

The Management of Toe Walking in Children with Autism Spectrum Disorder: "Cast and Go".

Background: Toe walking is associated with autism spectrum disorders (ASD). Correction of this “behavior” is a health challenge. The toe walker is affected by the contact refusal with the outside world: touching the ground as little as possible, trying to avoid any contact. A structured equines foot is a possible consequence. Method: We present the “Cast and Go” protocol, used in 22 idiopathic toe walker children with ASD treated from 2015 to 2020. The treatment was performed by a single senior experienced doctor with botulinum injection, ankle casts and rehabilitative therapies. All patients underwent pre- and post-treatment clinical evaluation using ankle dorsiflexion angle and casting number as treatment. We aimed to identify the intervention with the shortest acquisition time for the management of toe walking. Results: Our findings demonstrated the baseline ankle dorsiflexion angle influenced the casting number (p < 0.01) and male patients had a higher baseline ankle dorsiflexion angle than female patients (p < 0.01). No adverse events were observed. Conclusions: These findings suggested that the “Cast and Go” protocol could be a promising, dynamic and effective practice for toe walking disease in ASD patients.