Treatment Of Idiopathic Toe Walking Research Articles

A Pilot Study of Idiopathic Toe Walking: Measures and Outcomes

Abstract Date Presented 03/21/24 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 can inform standardized assessment and treatment of ITW. Primary Author and Speaker: Debra Hines Additional Authors and Speakers: Amy Armstrong-Heimsoth, Sarah A. Schoen

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.

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.

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...

Carbon Fiber Two-Pull Solid Ankle-Foot Orthoses versus Serial Casting in the Treatment of Idiopathic Toe Walking with Ankle Equinus Contracture

ABSTRACT Introduction Idiopathic toe walking (ITW) is a common pediatric diagnosis. Serial casting, a common treatment used for an ankle equinus contracture, may not be appropriate for all children. This pilot study investigated whether carbon fiber two-pull solid ankle-foot orthoses (CTP-AFOs) would have similar outcomes as serial casting in the treatment of children with a diagnosis of ITW and ankle equinus contracture. Materials and Methods Children with ITW (n = 35) were randomized to receive CTP-AFOs or serial casting. Assessments were at initial, posttreatment, and 4-month follow-up with therapy protocols until posttreatment. Results There was no statistical difference in active (<0.001) and passive (<0.001) dorsiflexion range of motion, the Observational Gait Scale (<0.001), the Pediatric Reach Test (<0.01) popliteal range of motion (<0.001), strength in dorsiflexion (<0.001) and plantarflexion (0.21), and the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (0.31). Both groups demonstrated significant improvement over time with therapeutic intervention performed by a physical therapist. Conclusions Carbon fiber two-pull solid ankle-foot orthoses are a noninferior alternative to serial casting in a population with ITW and ankle equinus contracture. Therapeutic interventions for treatment of ITW and ankle equinus contracture have demonstrated improvements in motor outcomes.

Orthotic treatment of idiopathic toe walking with a lower leg orthosis with circular subtalar blocking

BackgroundThere is no universally accepted treatment standard for idiopathic toe walking patients (ITW) in the current literature. None of the established methods provide homogenous satisfying results. In our department we treat ITW patients with lower leg orthoses with a circular foot unit for a total of 16 weeks. In this study we reviewed our database to evaluate the success of our treatment protocol for a 24 months follow up period.ResultsTwenty-two patients were included in this study. Age at the beginning of treatment was 7.0 years +/− 2.9 (range 2.5-13.1). Percentage of ITW at the beginning of treatment according to the perception of the parents was 89% +/− 22.2 (range 50-100). Immediately after the treatment with our device, percentage of ITW dropped to 11% +/− 13.2 (range 0-50). After 12 months, 73% of the patients (16/22) walked completely normal or showed ITW less than 10% of the day. After 24 months, 64% of the patients kept a normal gait (14/22).ConclusionThis study provides evidence that the treatment of idiopathic toe walking with lower leg orthoses with a circular foot unit results in satisfying long-term results in two thirds of the patients.

American and Australian family experiences while receiving a diagnosis or having treatment for idiopathic toe walking: a qualitative study

ObjectiveTo understand parent journeys while navigating diagnosis, assessment or treatment of their children with idiopathic toe walking (ITW).DesignMixed methods qualitative study: analyses of survey data from the measure of processes...

Exploring health professionals' understanding of evidence-based treatment for idiopathic toe walking.

Idiopathic toe walking (ITW) is an exclusionary diagnosis resulting in a child walking on the balls of their feet. Preferred treatment options may be due to the severity of the toe or the health professional preference There are limited guidelines supporting consistent treatment recommendations for this condition. This research aimed to understand agreement between health professionals' knowledge of evidence for common treatment strategies for ITW and if health professionals supported these strategies being used in clinical practice. An international online survey was opened to registered health professionals who treat children with ITW between July 2017 and March 2018. The survey had two components: (a) demographic variables and variables relating to knowledge of evidence about ITW treatments and (b) support for common treatment strategies. Additional data on strategy use, referrals, and preference were collected. Kappa statistics described intra-rater agreement between evidence knowledge and support. Multivariable regression analyses identified factors associated with the 10 most commonly preferred treatments. There were 908 international responses. Kappa agreement for paired correct responses determined a fair agreement for evidence support knowledge for four strategies including watch and wait (Kappa = 0.24), stretching (Kappa = 0.30), sensory integration strategies (Kappa = 0.40), and motor control strategies (Kappa = 0.24) and moderate responses for 13 others. No strategies had greater than moderate agreement between correct knowledge of evidence and strategy support. Profession, location, number of children seen in practice, and not correctly identifying the evidence factored into many of the most commonly used strategies for ITW (p < .05). The results from this study, which confirm a variety of interventions, are utilized in the management of ITW around the world. Furthermore, there remains a disconnection between paediatric health professionals' understanding of the evidence of common treatment strategies of ITW and a consensus for the treatment of this condition.

The Dynamic Baropodometric Profile of Children with Idiopathic Toe-Walking A Cross-Sectional Study.

Idiopathic toe-walking (ITW) gait may present in children older than 3 years and in the absence of a medical condition known to cause or be associated with toe-walking gait. It is unknown how this gait type changes pressure distribution in the growing foot. We sought to determine whether children with ITW gait exhibit different plantar pressures and temporal gait features than typically developing children. Children aged 3 to 6 years were recruited who had either a typical heel-toe gait pattern or a diagnosis of ITW. The ITW diagnosis was reported by the parent/caregiver and confirmed through history and physical examination. Temporal gait measures, peak pressures, and impulse percentages were measured. A minimum of ten unshod footprints were collected. Data were compared with unpaired t tests. The study included 40 children with typical gait and 56 with ITW gait. The ITW group displayed lower peak pressures at the hallux, midfoot, and hindfoot ( P < .05) and higher and lower pressure impulse percentages at the forefoot ( P < .001) and hindfoot ( P < .001), respectively. The ITW group spent a higher percentage of contact time at all areas of the forefoot and less at the midfoot and rearfoot ( P < .05). There were no significant differences in total step duration and foot progression angle between groups ( P > .05). There were differences in pressure distributions between groups. Understanding these differences may help us better understand the compensations or potential long-term impact that ITW gait may have on a young child's foot. Podiatric physicians may also consider the use of this equipment in the clinical setting to measure outcomes after treatment for ITW.

Does Idiopathic Toe-Walking Spontaneously Correct?: Commentary on an article by Pähr Engström, MD, PhD, and Kristina Tedroff, MD, PhD: "Idiopathic Toe-Walking: Prevalence and Natural History from Birth to Ten Years of Age".

Commentary Idiopathic toe-walking is a relatively common gait disorder of childhood but is quite rare in adults. Thus, it is clear that most idiopathic toe-walking cases are either treated adequately in childhood or spontaneously resolve. About half of the cases resolve by the age of 5 or 6 years, but less is known with regard to resolution in those whose idiopathic toe-walking persists beyond the age of 6 years. This study addresses our deficit in knowledge with regard to idiopathic toe-walking that has persisted into middle childhood. Can some of these individuals still resolve spontaneously? If not, do they require surgical treatment? We also know that idiopathic toe-walking is frequently seen in children with autism spectrum disorder and other neurodevelopmental challenges not traditionally considered to have a motor component. Many of these, for example, attention deficit hyperactivity disorder (ADHD), tend to be diagnosed only after the child has begun school. Two questions thus arise. The first is whether the toe-walking in those with such a disorder differs from the toe-walking in those who have no such problem. A corollary question is whether treatment of idiopathic toe-walking in a child with a late diagnosis of a cognitive disorder should change as a result of the diagnosis. This study by Engström and Tedroff provides information with regard to both questions. The authors report that 6 of the 26 neurologically normal children with idiopathic toe-walking at the age of 5.5 years spontaneously resolved by the age of 8 years and another 7 children resolved by the age of 10 years. Thus, of the 63 children who were toe-walking at the age of 2 years, 37 (59%) had resolved by the age of 5.5 years, 43 (68%) had resolved by the age of 8 years, and 50 (79%) had resolved by the age of 10 years. Five had required surgical treatment, 4 before the age of 8 years and 1 afterward. Of the original 7 toe-walkers with neurodevelopmental disorders, 3 had stopped toe-walking before the age of 5.5 years and 2 more had stopped toe-walking by the age of 10 years. Thus, 5 (71%) of 7 patients had resolved by the age of 10 years, not too dissimilar from the results in the normal patients. However, if the 10 patients with a late neurologic diagnosis are added to the neurodevelopment group and are subtracted from the normal group, spontaneous correction is seen in 85% of the normal patients and only 59% of the neurodevelopmental group, suggesting a worse prognosis in this group. We have little information with regard to what happens with children with persistent idiopathic toe-walking during the growth spurt of adolescence. Can spontaneous resolution still occur in some patients? Or should we expect an increase in gastrocnemius-soleus complex contracture with the increased growth velocity of adolescence? We simply do not know. One weakness of this study is the lack of formal gait analysis in a gait laboratory in determining whether the idiopathic toe-walking had resolved. Using gait analysis, Stott et al.1 documented kinematic abnormalities in 12 of 13 mature patients with resolved idiopathic toe-walking, but the changes were detectable visually in only 3 subjects. In addition, O’Sullivan and O’Brien reviewed 102 subjects with presumed idiopathic toe-walking2. Gait analysis was believed to be consistent with the diagnosis in only 81 (79.4%) of the cases, with 21 (20.6%) being atypical, most showing signs of spasticity. These results call into question both the accuracy of diagnosis of idiopathic toe-walking in the current study by Engström and Tedroff and the certainty of resolution. This study also offers little information with regard to the efficacy and timing of treatment. Other studies have questioned the long-term value of most nonoperative modalities, including physical therapy, botulinum toxin, serial casting, and orthoses3. Surgical treatment has been shown to be effective4, but we have little information about the optimal timing of the surgical procedure, the specific method of lengthening of the gastrocnemius-soleus complex, or the strength or functionality of the gastrocnemius-soleus complex following lengthening in idiopathic toe-walking. To fill the gaps noted above, I encourage the authors to follow these children until skeletal maturity and to do a final evaluation at that time using state-of-the-art gait analysis.

Long-term gait outcomes following conservative management of idiopathic toe walking

BackgroundIdiopathic toe walking is a diagnosis of exclusion characterized by a persistent toe–toe gait pattern after three years of age. Treatment for toe walking includes physical therapy, orthotics, casting, Botulinum Toxin A injection into gastrocnemius/soleus muscles, and/or surgery; yet, little evidence exists regarding long-term treatment effects. Research questionThe objective of this study was to explore the differences in longer-term gait outcomes and severity of idiopathic toe walking between children treated actively with casting or inactively following recommendations for stretching. MethodsForty-three adolescents and young adults (14.3–28.8 years; 21 females, 22 males) who had participated in an idiopathic toe walking classification study as children, returned for repeat physical examination and three-dimensional computerized gait analysis (13.4 years follow-up, range 9.4–17.8 years); 23 participants had received active treatment with casting and ankle foot orthotics ± Botulinum Toxin A injection as children and 20 participants had received inactive treatment with recommended stretching exercises. Gait analysis data were compared retrospectively from baseline to follow-up using analysis of variance; toe walking severity was compared using a Wilcoxin Signed-Rank Sums test. ResultsAnkle angle at initial contact, peak dorsiflexion in stance, and toe walking severity improved significantly in the active treatment group only at follow-up. Significant improvement in peak ankle power and timing of ankle kinematics and kinetics in the gait cycle were found in both groups; however, greater changes occurred in the active treatment group. Both groups showed significantly improved internal plantar flexor moments, whereas knee extension increased in stance and passive ankle dorsiflexion decreased in both groups at follow-up (p = 0.001). Intermittent toe walking was reported in 49% (21/43) of participants at follow-up. SignificanceThe results of this study suggest that improvement in ankle kinematic timing and ankle kinetic gait analysis variables is sustainable, independent of conservative treatment for idiopathic toe walking in childhood.

Literature Review of Idiopathic Toe Walking: Etiology, Prevalence, Classification, and Treatment.

The main objective of this review is to gather the information available about idiopathic toe walking (ITW), its prevalence and classification, and possible therapeutic approaches. In addition, this review aims to clarify the differences between idiopathic toe walkers and tiptoe walkers with underlying neurological or muscle deficiency as primary conditions. Understanding its causes and learning to make a differential diagnosis will help determine the adequate therapeutic approach. This is a review of different articles and case studies from 1967 to 2016. The information was gathered to update and unify all the information about ITW that has been published. The literature offers limited research regarding the possible etiology, prevalence, classification, and evaluation of ITW. This review puts together all the information regarding the etiology, prevalence, classifications, evaluation, and treatment of ITW. Level IV.

Conservative treatment of idiopathic toe walking

Conservative treatment of idiopathic toe walking

Marcha em pontas idiopática em idade pediátrica

Toe walking has an estimated incidence of 7-24% in the general pediatric population and is a frequent cause of referral to outpatient pediatric neurology. Idiopathic toe walking occurs in healthy children without spasticity and normal osteotendinous reflexes, is evident from the beginning of independent gait and always bilateral and not progressive. The etiology is unknown, so it is a diagnosis of exclusion. Thus, in evaluating these children is essential to be alert to sensory or motor signs because this gait pattern may be the first sign of pathologies such as cerebral palsy, congenital muscular dystrophy or autism spectrum disorder. Therapeutic options include more conservative treatments such as physiotherapy, use of orthopedic footwear, splints or orthotics; or more invasive treatments such as use of serial casts, botulinum toxin or surgery.The aim of this article is: to address epidemiological and pathophysiological aspects, review the clinical presentation and differential diagnosis and propose guidelines for the monitoring and treatment of idiopathic toe walking in pediatric age.

Toe walking: causes, epidemiology, assessment, and treatment.

The present review includes the most up-to-date literature on the causes, epidemiology, diagnosis, and treatment of toe walking. The prevalence of toe walking at age 5.5 years is 2% in normally developing children, and 41% in children with a neuropsychiatric diagnosis or developmental delays. A recent systematic review concluded that there is good evidence for casting and surgery in the treatment of idiopathic toe walking, with only surgery providing long-term results beyond 1 year. Botox combined with casting does not provide better outcomes compared with casting alone. Ankle-foot-orthoses restrict toe walking when worn, but children revert to equinus gait once the orthosis is removed. Toe walking can occur because of an underlying anatomic or neuromuscular condition, but in the majority of cases toe walking is idiopathic, without a discernable underlying cause. For some families, toe walking may simply be a cosmetic concern, whereas in other cases it can cause pain or functional issues. Treatment for toe walking is based on age, underlying cause, and the severity of tendon contracture. Described treatments include casting, chemical denervation, orthotics, physical therapy, and surgical lengthening of the gastroc-soleus-Achilles complex. A careful history, clinical exam, and selective diagnostic testing can be used to differentiate between different types of toe walking and determine the most appropriate treatment for each child.

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.

Treatment for idiopathic toe walking: a systematic review of the literature.

To assess the effectiveness of currently available treatment options for idiopathic toe walking on the 3 main levels of the World Health Organization International Classification of Functioning, Disability, and Health for Children and Youth (ICF-CY). A systematic search from 1966 to December 2013 in MEDLINE, Current Contents, CINAHL and the Cochrane Library of full-length articles addressing clinical efficacy of treatment in children aged 2-18 years. Studies were evaluated using both the Oxford Centre for Evidence-Based Medicine (OCEBM) levels of evidence and the Methodological Index for Non-Randomised Studies (MINORS). Outcomes were analysed in accordance with the ICF-CY. One randomized controlled trial and 18 observational studies were identified. The randomized controlled trial was scored OCEBM level 1, whereas the other studies were scored level 4. The MINORS scores ranged from 2 to 18. There is preliminary evidence for beneficial effects of serial casting and surgery on passive ankle dorsiflexion as well as on walking kinetics and kinematics, although normalization does not seem to occur. Botulinum toxin type A does not improve the results of casting. Only after surgery are sustainable effects lasting > 1 year reported. Effectiveness on functional activities and social participation has yet to be demonstrated.

Idiopathic toe walking – are common podiatric treatment options based on evidence?

Idiopathic toe walking (ITW) is a condition that commonly presents to podiatrists. This presentation aims to give an overview of the quality of literature focused on the treatment of ITW and determine if common podiatric treatment modalities are evidence based. 24 articles reporting treatment modalities were appraised against the National Health and Medical Research Council Levels of Evidence. There currently is no evidence of any single treatment option having long term effect on ITW gait. The highest level of evidence was in support of serial casting or surgery with some evidence supporting the use of Botulism toxin Type A. Footwear and orthotic intervention with or without stretching programs are reported treatments with no rigorous studies to support these modalities yet anecdotally these are reported effective. This article aims update the knowledge of podiatrists, to enhance how children who present with this gait style can be managed and highlight areas for future research.

Treatment of idiopathic toe-walking in children with autism using GaitSpot Auditory Speakers and simplified habit reversal

This study aimed to examine the effectiveness of a simplified habit reversal procedure (SHR) using differential reinforcement of incompatible behaviour (DRI) and a stimulus prompt (GaitSpot Auditory Squeakers) to reduce the frequency of idiopathic toe-walking (ITW) and increase the frequency of correct heel-to-toe-walking in three children with autism. The study involved a delayed multiple baseline changing criterion design across individuals. Firstly, a baseline phase was conducted to determine the number of intervals where ITW occurred. Secondly, the GaitSpot Auditory Squeakers were paired with reinforcers. Thirdly, children wore GaitSpot squeakers over the heels of their feet under their shoes for a small number of 10 min sessions and when weight was placed on their heel, a squeak was emitted which was subsequently reinforced. Fourthly, the length of time the children wore the GaitSpot Auditory Squeakers was extended. Finally, the GaitSpot Auditory Squeakers were faded out and tests for generalisation and maintenance of heel-to-toe walking were conducted. The intervention produced substantial reductions in ITW across all participants though degree of reduction differed. The role of SHR and additional modifications for the treatment of ITW are discussed.

Comprehensive Outcomes of Surgically Treated Idiopathic Toe Walkers

The treatment of idiopathic toe walking in children can include surgical lengthening of the gastrocnemius/soleus complex after conservative options have been ineffective. Previous outcome reports of surgery for idiopathic toe walkers have largely been limited to assessing the sagittal plane motion of dorsiflexion/plantar flexion with minimal quantitative preoperative and postoperative analysis. The purpose of this study was to comprehensively assess the outcome of idiopathic toe walkers that had been treated surgically. Fourteen children seen in our motion analysis laboratory that underwent gastrocnemius or tendo-Achilles lengthening for idiopathic toe walking were retrospectively reviewed. Preoperatively, this group had significantly greater anterior pelvic tilt than normal, decreased peak knee flexion in swing, greater external foot progression, and the expected increased plantar flexion (P < 0.01). Postoperatively, anterior pelvic tilt decreased by a mean of about 4 degrees (P < 0.01), only for the group that had tendo-Achilles lengthening because the gastrocnemius group was close to normal preoperatively, and peak knee flexion normalized. The foot progression angle of this group did not change from preoperative values and remained significantly more external than normal, although dorsiflexion in stance significantly improved after surgery (indicating the goal of the surgery was achieved). Increased external foot progression in idiopathic toe walkers is apparently due to increased external tibial torsion and/or external hip rotation but was unaffected by gastrocnemius/soleus surgical lengthening. Significant improvement occurred on an overall index of gait variables, indicating surgery can be an effective treatment of idiopathic toe walkers.