Persistent Toe Walking Research Articles

The Prevalence of Persistent Toe Walking in Children With and Without Autism Spectrum Disorder and the Odds of Subsequent Surgery

Persistent toe walking is associated with autism spectrum disorder. The true prevalence of persistent toe walking and odds of progression to surgery in children with and without autism remains unclear. This retrospective descriptive study identified patients ages 3 to 17 years who were enrolled in our healthcare system over a 2-year period. Using international classification of disease codes, we identified all children with autism and persistent toe walking, and excluded children with conditions that may independently cause toe walking. Data on Achilles lengthening surgeries, sex, race and body mass index was gathered. The toe walking prevalence amongst children with and without autism was calculated. Multivariable logistic regression analysis controlling for sex, race and body mass index was used to determine independent risk factors for persistent toe walking and surgery. Of the children who met inclusion criteria (N = 284,925), 4622 (1.6%) had persistent toe walking. Prevalence of persistent toe walking was higher amongst children with autism (6.3% vs 1.5%, p < .01), as were odds of persistent toe walking (OR 4.13, 95% CI 3.74 to 4.56, p < .01). Males and White patients had higher odds of persistent toe walking compared to females and patients of any other race, respectively (p < .01 for all). Although children with autism and toe walking had higher rates of surgery than their counterparts without autism (4.3% vs 2.6%, p = .04), this difference was not significant after controlling for sex, race and BMI (OR 1.59, 95% CI 0.95 to 2.69, p > .05).

Persistent Toe-Walking in a Developmentally Normal 7-year-old Girl

1. Ngoc Thien T. Nguyen, MD, MPH* 2. Eyal Ben-Isaac, MD*,† 3. Mikako Warren, MD‡ 1. *Department of Pediatrics, Children’s Hospital Los Angeles, California 2. †Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California 3. ‡Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California A 7-year-old, developmentally normal girl with a history of toe-walking presents to an emergency room with complaints of worsening back and leg pain with limp. She has walked on her toes since she learned to ambulate at 18 months. However, in the past she was able to correct her gait when reminded. Family was reassured that these symptoms were most likely benign as the child continued to otherwise do well and had symptom-free periods. In the past 2 years, she developed bilateral lower extremity pain, which was more frequent at night and improved with massaging of the extremities. Initially her symptoms were attributed to growing pains. However, in the past month, massage no longer relieved the pain. In addition, she now has been having back and bilateral knee pain. Her symptoms are more prominent on the right side. Most recently she has been hunching to the right when walking and having extended periods of toe-walking. On examination, she has a right-sided lower thoracic prominence and levoscoliosis of the thoracic region. She exhibits an antalgic gait with toe-walking more prominent on the left side along with a left-sided foot drop. Strength is decreased in the left lower extremity, and sensation is intact throughout. She does not demonstrate clonus or any appreciable cranial nerve abnormalities. Further workup with imaging and pathology revealed the diagnosis. A common benign etiology for lower extremity pain in school-aged children is “growing pains.” There is no …

Autism and toe-walking: are they related? Trends and treatment patterns between 2005 and 2016.

PurposeThis study quantified toe-walking trends and treatment decisions in patients with autism spectrum disorder (ASD) in the United States between 2005 and 2016 using a large national private-payer database.MethodsA retrospective database review was performed on paediatric patients with ASD, and for International Classification of Diseases-9/10 diagnosis codes for toe-walking. Patients were filtered based on treatment type by Current Procedural Terminology (CPT) code. Continued toe-walking rates were assessed for each patient population and treatment group. A Pearson’s chi-squared test was used to evaluate differences in group characteristics.ResultsOf 2 221 009 paediatric patients in the database, 5739 patients had a diagnosis of ASD, and 8.4% of patients with ASD also had a diagnosis of toe-walking (n = 484). For typically developing children in the database, 0.47% of patients had a diagnosis of persistent toe-walking. In all, 59.3% of ASD patients underwent physical therapy, 7.4% serial casting and 3.3% surgical correction, compared with 38.1%, 3.6% and 1.2% of normally developing children, respectively (chi-square 6.4031; p < 0.040699). Without intervention, 63.6% of patients with ASD continued to toe-walk within ten years of their diagnosis, with 19.3% of patients without ASD (chi-square 82.9762; p < 0.0001).ConclusionThis study supports the association between a greater prevalence of toe-walking in children with ASD. We showed that patients with ASD and toe-walking receive surgical correction at nearly triple the rate of children without ASD who toe-walk. The continued rate of toe-walking is comparable between treatment groups as well as between ASD and typically developing children. Typically developing children have higher rates of toe-walking resolution without intervention than children with ASD.Level of evidenceLevel II

Toe Walking Assessment in Autism Spectrum Disorder Subjects: A Systematic Review.

There is increasing evidence that autism spectrum disorder (ASD) subjects have also motor impairments. Toe walking (TW) is a phenomenon that can be found in ASD subjects during gait, even if this condition was found not to be necessarily related only to walking, since these children often also stand and run on their tiptoes. Since persistent TW in ASD subjects may contribute to secondary shortening of the Achilles's tendon, it becomes important to have an assessment tool and/or outcome measure for both the clinical and rehabilitative settings. The aim of this systematic review is to critically evaluate and describe the methods employed to assess toe walking in ASD subjects. The systematic review protocol was previously registered on PROSPERO. We conducted an extensive literature search in PubMed, CINAHL, PsycINFO, The Cochrane Library, and Scopus databases. There were no restrictions on the types of study design eligible for inclusion. Ten studies were included in the systematic review. Risk of bias of the included studies was conducted using the following instruments depending on the study types: STROBE Statement, Cochrane risk of bias tool, and CARE checklist. Almost all the included studies (8/10) proposed a tip-toe behavior (TTB) assessment only during walking. Nine out of ten of the included studies assessed TTB using a qualitative methodology. The results evidenced the heterogeneity of qualitative methods and a lack of a structured quantitative test to assess toe walking in ASD subjects. Autism Res 2018, 11: 1404-1415. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY ABSTRACT: Toe walking (TW) is a phenomenon that can be found during ASD subject's gait. The persistence of this behavior may contribute to secondary Achilles's tendon shortening. In this perspective it becomes important to have an assessment tool and/or outcome measure for both the clinical and rehabilitative settings. The current systematic review aimed to describe the methods employed to assess TW. The results evidenced the lack and the need of a structured quantitative test to assess TW in ASD subjects.

Outcomes of Noninvasively Treated Idiopathic Toe Walkers

Idiopathic toe walking (ITW) causes a common problem in pediatric orthopaedics. In the literature, numerous treatment options have been reported, but consensus about the management of ITW is still missing. The aim of the current study was to evaluate conservative treatment with pyramidal insoles. A total of 193 patients underwent conservative treatment between January 2010 and June 2013. Mean age at the beginning of the treatment was 7.75 ± 0.23 years (range 2.0-17.0 years). For all patients, demographic data, comorbid diseases, passive range of motion (ROM), persistent toe walking, and performed operations were retrospectively evaluated. Following operative treatment was defined failure. Eight (4.15%) patients underwent Achilles tendon lengthening operation after mean therapy time of 2.72 years (range 0.1-7.0 years), 174 cases were treated successfully (90.16%). In 50 cases, toe walking suspended completely after mean therapy time of 2.83 years. In cases of failure, patients were older at diagnosis and at the beginning of the treatment. Mean passive ROM increased over the time. In cases of failure, ROM decreased from the first to the second examination. Conservative treatment of ITW using pyramidal insoles can be effective. Ankle dorsiflexion significantly improved in the patients who were successfully treated. Therapy should start early. A decrease of ROM under therapy should lead to critical revisal of individual therapy. Levels of Evidence: Therapeutic, level IV: Case series.

The effect of persistent toe walking on the skeletal development of the pediatric foot and ankle.

prognostic level III.

Toe Walking: When Do We Need to Worry?

Toe walking refers to the lack of heel strike during the stance phase of the gait cycle. It is a common variation of normal gait development in children. Persistent toe walking past 2-3 years of age warrants further evaluation as toe walking can be associated with cerebral palsy, muscular dystrophy, and autism spectrum disorders. The diagnosis of idiopathic toe walking is a diagnosis of exclusion used for children with persistent toe walking and no associated medical condition. Despite variable pathophysiology, the treatment of toe walking has similarities across diagnoses as it is focused on the maintenance of range of motion through the ankle.

Fifteen-minute consultation: A child with toe walking

Toe walking is a common developmental phenomenon in young children. It is usually benign and self-limiting. Toe walking can be a presenting sign of some serious underlying disorders and idiopathic...

Non-invasive serial casting to treat idiopathic toe walking in an 18-month old child

Idiopathic toe walking is characterized by persistent toe walking in the absence of clinically diagnosed neuromuscular disease. Treatment options in children diagnosed with idiopathic toe walking include: observation, physical therapy, serial casting, or Achilles tendon (heel cord) lengthening surgery. In this case report, we present a non-invasive serial casting protocol to treat severe and persistent toe walking in an 18-month old child, diagnosed as an idiopathic toe walker following neurological examination. A series of below knee casts was used to provide a consistent stretch to the plantar flexor muscles. Upon removal of each set of casts, passive range of motion at the ankles was measured with a goniometer. Four sets of casts, each lasting approximately one week, increased passive ankle dorsiflexion to 10° of neutral and established a heel-toe walking gait. Improvements in ankle range of motion and gait were maintained upon repeated examinations at 3, 7, and 12 months post-casting. These results demonstrate that non-invasive procedures, such as serial casting, can be successful in very young children diagnosed as idiopathic toe walkers. Early identification and intervention for this diagnosis may eliminate the need for invasive surgeries and associated risks in this population.

Toe Walking in Autism

Toe walking has been associated with language disorders and autism. To better understand the association between persistent toe walking and sensory and motor variables in children with autism, the degree of toe walking was compared with an estimate of the severity of sensory integration dysfunction symptoms and the presence of residual components of the tonic labyrinthine in supine reflex pattern in 61 children younger than 37 months of age with newly diagnosed autism. There was no association between the presence of toe walking and sensory symptoms (P = .5298) or language age (P = .6142), but there was an association between toe walking and the presence of components of the tonic labyrinthine reflex (P = .04222). These preliminary results support the contribution of subtle motor deficits to the evolution of some behaviors associated with autism.

Outcome after conservative and operative treatment of children with idiopathic toe walking: a systematic review of literature

When toe walking persists after the age of 2 years in the absence of any neurological or orthopedic abnormalities, it is referred to as idiopathic toe walking (ITW). When the plantar flexion persists, an equinus contracture can develop. There is inconsistency in the treatment of choice of this condition. A systematic review of observational studies comparing cast and operative treatment of children with ITW or equinus contracture was undertaken. Ten trials involving 298 participants were included. Ankle dorsiflexion increased 3.1° (median follow-up 3 years) in the cast treatment group and 14.2° (median follow-up 3.3 years) in the surgical group. No significant differences between groups were found in terms of persistent toe walking and complications after treatment. We have found favorable results in improvement of dorsiflexion for children treated by surgery. However, due to heterogeneity of patient groups, sample size and follow-up, no firm conclusions on a favorable role of surgery or cast treatment could be drawn in the treatment of ITW or equinus contracture.

Muscle volume and motor development in spastic cerebral palsy

describe volumetric deficits in the medial gastrocnemiiof young children (2–5y) with spastic CP of 22%. Their paperis important because it challenges a prevalent view that thedevelopment of musculoskeletal deformity is associated withthe older child. The age range of the participants in this paperis such that the authors come tantalizingly close to answeringa fundamental question of muscular deformity and develop-ment in spastic CP: ‘Is delayed muscle development causedsolely by disuse secondary to the delayed acquisition of com-promised motor skills or is lack of muscle development moredirectly related to the superposition of cerebral injuries on adeveloping motor system?’ If the latter, then lack of plantar-flexor muscle growth in infancy may be an important factor tothe delayed acquisition of motor milestones and even, in part,responsible for the persistent toe-walking pattern observed inthis group.How can deficits in calf muscle volume contribute to thedevelopment of a toe-walking pattern? The members of theplantarflexor muscle group are essential to the maintenance ofstanding balance and, in gait, to the support and progressionof the body. In the typically developing, these muscles appearto work at close to 50% of their capacity during heel-toe walk-ing.

Persistent Toe Walking in Autism

The records of 954 ambulatory children presenting for initial evaluation to a university developmental pediatrician were reviewed for the prevalence of persistent toe walking and associated tight heel cords. The incidence of persistent toe walking (20.1%) and tight heel cords (12.0%) were found to be higher in 324 children with an autistic spectrum disorder but lower (10.0%/3.0%) in 30 children with Asperger syndrome. These results confirm the previously reported high incidence of toe walking in children with autism and with language disorders and also raise the possibility of a secondary orthopedic deformity that can complicate long-term management of these patients.

Toe-walking

In this issue of The Journal, Pernet et al of Robert Debré University Hospital examine the topic of early onset toe-walking in toddlers. Using the Grand Rounds format, they present the case of a 17-month-old boy with persistent toe-walking. In addition to the routine clinical information and photographs, they have provided a video of his gait, which is available at www.jpeds.com. After extensive discussion of the case including differential diagnosis, Pernet et al discuss the most effective current therapy for the child's problem, which was diagnosed as idiopathic toe-walking.Article page 496 ▸ In this issue of The Journal, Pernet et al of Robert Debré University Hospital examine the topic of early onset toe-walking in toddlers. Using the Grand Rounds format, they present the case of a 17-month-old boy with persistent toe-walking. In addition to the routine clinical information and photographs, they have provided a video of his gait, which is available at www.jpeds.com. After extensive discussion of the case including differential diagnosis, Pernet et al discuss the most effective current therapy for the child's problem, which was diagnosed as idiopathic toe-walking. Article page 496 ▸ Early Onset Toe-Walking in Toddlers: A Cause for Concern?The Journal of PediatricsVol. 157Issue 3PreviewA child was born to non-consanguineous, healthy parents. Pregnancy and delivery were uneventful. At 17 months, he was seen by the pediatric emergency department because of mild cranial trauma, and clinical examination disclosed a small parietal hematoma. Neurologic examination was normal, except for a bilateral equinus foot position at rest (Figure) and toe-walking (Video 1; available at www.jpeds.com ). Passive ankle dorsiflexion was limited to less than 10 degrees and was painful. His gait had a toe-to-toe pattern, and he was unable to rock back into a flat-foot position when cued. Full-Text PDF

Idiopathic toe walking: what should a general paediatrician know about it?

Background Idiopathic toe walking (ITW) is defined as a condition in which children walk with a tip-toe gait pattern after the age of 2 years without evidence of neurologic, orthopaedic or psychiatric disease. Untreated, persistent toe-walking may place children at increased risk for falling or developing limitations in ankle mobility and structural abnormalities. However, there is little published literature on the natural history of this condition. Aims To raise awareness about the natural history of ITW and the treatment options among paediatricians. Methods It is a retrospective study. Patients were identified from physiotherapy department database. Results There were 40 patients (M:F 2.3:1). 63% were referred directly to physiotherapists, 27% to paediatricians and rest 10% to orthopaedicians. Age of referral varied from 13 months to 9 years (mean=4.2 years). No foot or toe abnormalities were identified on routine first day neonatal examination. Expressive speech was delayed in nine patients (22.5%).Family history was positive in 25% cases. All patients were advised dorsiflexion exercises and stretches to tendoachillis and hamstrings. 29 patients (72%) were given Pedro boots, 19 were given foot insoles (47%). One patient was given AFO splint. 18 children (45%) were given serial castings. Five patients did not need any orthotic help. All children were followed up by physiotherapists. Mean duration of follow up was 2.5 years (range 6 months to 6.5 years). No child has required surgical correction so far. Five cases were discharged from follow up. Residual toe-walking is still present in 35 children. Conclusions ITW is a well defined clinical entity with strong family history. Speech delay is an important association with ITW. A significant proportion requires physiotherapy input for long time with nearly half needing serial casting. Further follow up would help define natural history and outcome of these patients.

Toe-walking as the first presenting symptom of Emery-Dreifuss muscular dystrophy type 1

Up to 10% of the children show persistent toe walking patterns. Toe walking usually starts with or shortly after beginning to walk. Clinical and differential diagnosis of the common idiopathic toe walking and secondary toe walking caused by neuromuscular diseases is often difficult.

Transient dystonic toe‐walking: differentiation from cerebral palsy and a rare explanation for some unexplained cases of idiopathic toe‐walking

We report on seven children (five males, two females) who presented with marked, often asymmetrical, toe-walking from onset of independent walking, associated with abnormal foot postures and increased tone at the ankles with characteristics of dystonia. Most of the children had presented with unusual pre-walking locomotion and a mild delay in independent walking. They did not fit into the usual categories of 'habitual' toe-walking or congenital short tendo calcaneus but nor did they have the clinical signs of spastic diplegia or of a peripheral neuromuscular disease. Normalization occurred progressively in the second to fourth years of life. The children were re-examined several years later (1 to 11y) and were normal. We believe that their persistent toe-walking corresponded to a variant of 'transient focal dystonia of infancy'. Knowledge of its existence may justify a period of observation without special investigations, surgery, or casting.

Effect of Functional Electrical Stimulation on asymmetries in gait of children with hemiplegic cerebral palsy

Background and purpose The gait of children with hemiplegic cerebral palsy is often characterised by toe walking and asymmetry in other temporal spatial parameters. Persistent toe walking impairs balance, resulting in shortening of the musculo-tendinous unit and reduced function. Current interventions to maintain range of movement at the ankle and improve walking patterns show mixed results. An alternative may be Functional Electrical Stimulation (FES), which is effective in assisting walking in adults, however there is limited research assessing its effectiveness or acceptability in children. The aims of this study were to quantify gait asymmetries, assess the effect of FES on these in an ambulant group of hemiplegic children and evaluate user perspective. Methods A ABA design was used, with stimulation applied in phase B, replacing any splint normally worn. Heel–toe contact pattern and other temporal spatial parameters of gait were measured in 12 children, before, during and after applying FES to the ankle dorsiflexors. Acceptability of the intervention and user perspective were investigated through use of a questionnaire. Results The greatest asymmetries were in heel–toe contact patterns and double stance times. Heel–toe contact pattern and symmetry were both improved with stimulation. There was a clear trend toward reduction in affected side pre-swing double stance time and a move toward symmetry. Mean swing and stance times were close to symmetry with and without stimulation. Electrical stimulation was generally well tolerated. Conclusions Electrical stimulation may be an effective intervention, when used functionally, to improve asymmetrical walking patterns. Further research is needed to refine selection criteria of subjects who may benefit and to optimize use of stimulation.

Idiopathic toe‐walking: a review

Developmental Medicine & Child NeurologyVolume 41, Issue 12 p. 846-848 Free Access Idiopathic toe-walking: a review Debra A Sala MS PT, Corresponding Author Debra A Sala MS PT Research Physical Therapist, Center for Neuromuscular and Developmental Disorders, Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003 * Correspondence to first author at address above.Search for more papers by this authorLisa H Shulman MD, Lisa H Shulman MD Assistant Clinical Professor of Pediatrics, Director of Infant/Toddler Services, Children's Evaluation and Rehabilitation Center,Search for more papers by this authorRose F Kennedy, Rose F Kennedy Center University Affiliated Programs, Albert Einstein College of Medicine, BronxSearch for more papers by this authorAlfred D Grant MD, Alfred D Grant MD Clinical Professor, New York University Department of OrthopedicsSearch for more papers by this authorMary Lynn Y Chu MD, Mary Lynn Y Chu MD Associate Director, Center for Neuromuscular and Developmental Disorders, Hospital for Joint Diseases, New York, NY 10003, USA.Search for more papers by this author Debra A Sala MS PT, Corresponding Author Debra A Sala MS PT Research Physical Therapist, Center for Neuromuscular and Developmental Disorders, Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003 * Correspondence to first author at address above.Search for more papers by this authorLisa H Shulman MD, Lisa H Shulman MD Assistant Clinical Professor of Pediatrics, Director of Infant/Toddler Services, Children's Evaluation and Rehabilitation Center,Search for more papers by this authorRose F Kennedy, Rose F Kennedy Center University Affiliated Programs, Albert Einstein College of Medicine, BronxSearch for more papers by this authorAlfred D Grant MD, Alfred D Grant MD Clinical Professor, New York University Department of OrthopedicsSearch for more papers by this authorMary Lynn Y Chu MD, Mary Lynn Y Chu MD Associate Director, Center for Neuromuscular and Developmental Disorders, Hospital for Joint Diseases, New York, NY 10003, USA.Search for more papers by this author First published: 13 February 2007 https://doi.org/10.1111/j.1469-8749.1999.tb00553.xCitations: 5AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat References 1 Hall JE, Salter RB, Bhalla SK. (1967) Congenital short tendo calcaneus. Journal of Bone and Joint Surgery 49B: 695– 7. 2 Griffin PP, Wheelhouse WW, Shiavi R, Bass W. (1977) Habitual toe-walkers. Journal of Bone and Joint Surgery 59A: 97– 101. 3 Kalen V, Adler N, Bleck EE. (1986) Electromyography of idiopathic toe walking. Journal of Pediatric Orthopedics 6: 31– 3. 4 Katz MM, Mubarak SJ. (1984) Hereditary tendo Achillis contractures. Journal of Pediatric Orthopedics 4: 711– 4. 5 Shulman LH, Sala DA, Chu MLY, McCaul PR, Sandler BJ. (1997) Developmental implications of idiopathic toe walking. Journal of Pediatrics 130: 541– 6. 6 Hicks R, Durinick N, Gage JR. (1988) Differentiation of idiopathic toe-walking and cerebral palsy. Journal of Pediatric Orthopaedics 8: 160– 3. 7 Caselli MA, Rzonca EC, Lue BY. (1988) Habitual toe-walking: evaluation and approach to treatment. 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Developmental implications of idiopathic toe walking

Objective: To determine whether children with persistent toe walking, without suspected developmental problems, and with normal results after neurologic examination, who were seen in an orthopedic clinic demonstrate delays in language development, gross or fine motor skills, visuomotor development, sensory integration function, or evidence of behavioral problems through a comprehensive multidisciplinary evaluation. Study design: A prospective, descriptive study of 13 children (mean age = 3.9 years) referred for idiopathic toe walking. Each child was evaluated by a pediatric neurologist, developmental pediatrician, speech/language pathologist, occupational therapist, and physical therapist. Results: On developmental screening, 7 of 13 children demonstrated delays and 3 were questionably delayed; all 10 had speech/language deficits. Speech/language evaluation showed that 10 of 13 (77%) had receptive or expressive language delays or both. Occupational and physical therapy evaluations found 4 of 12 (33%) had fine motor delays, 4 of 10 (40%) had visuomotor delays, and 3 of 11 (27%) had gross motor delays. Conclusions: Idiopathic toe walking was most often associated with speech/language delays, but delays in other areas were also present. We suggest that idiopathic toe walking should be viewed as a marker for developmental problems and recommend that any child with this condition should be referred for a developmental assessment. (J Pediatr 1997;130:541-6)