Pediatric Toe Walking ChandaStrzyzewski, PT
I attended a workshop titled “Effective Evaluation, Assessment, and Treatment of Pediatric Toe Walking. Toe walking is a fairly common pediatric problem. This course was quite PT-specific, but did include some information that others might find interesting.
Many people feel that children will outgrow the toe walking when they are young. However, research shows that the foot becomes formed with history of use, and the bones and shape are not complete until approximately 6.5 years old. Therefore, it is important to start treating these kids as early as possible, preferably before 3 years, to avoid improper bone formation. Many toe-walkers actually use a “controlled fall” when walking, where they move quickly and somewhat stumble, in order to hold themselves up against gravity. When they are up on their toes, their center of mass is pushed forward, but they often don’t have the strength in their calf muscles to hold them upright and slow themselves down. Toe walkers also do not develop active pronation and supination of the foot (rotatingof the foot sideways up and down), therefore they often have to develop other compensation strategies to maintain their balance when reaching or when on unstable surfaces. In addition, in normal gait, as you step forward, your lower legs moves forward over a flat foot, causing it to flex approximately 10 degrees. In toe walking, these muscles are often tight, not allowing such progression.
There are many methods out there for treatment of a child that toe walks. Sometimes a brace is used to get the foot flat. However, this has to be looked at closely, because some will impair range of motion instead of help it. In addition, oftentimes if the brace is kept on all the time, the child will become dependent on the brace and lose more strength. Therefore it is imperative that a strengthening program be included with this. In many instances, giving a child a heel wedge will finally give them some contact to the floor, thus giving the calf muscles more feedback. This often naturally strengthens the muscles and the heel wedge can then begradually decreased and allows the foot to become flat during gait.
Botox is another method that is used to treat toe walking. Essentially it is meant to decrease the spasticity in the calf muscles in order to allow the front of the leg to strengthen and allow it to flex. However, it does not address the reason for the movement disorder in the first place. It will often weaken an already weak muscle, and on its own does not teach the dominated muscle to function. Again, a strengthening program is imperative with muscle re-training to reduce the toe walking.
Some children also undergo surgery to correct this problem. However, the result is that these muscles are often over-weakened and over-lengthened. In addition, the scar tissue that is formed is also weaker then the surrounding muscle tissue. A lot of work is required before and after surgery to strengthen the surrounding and then affected muscles to get the maximum benefit.
In many instances, strengthening in functional activities and manual therapy to increase the range of motion can help retrain the muscles and get a more natural gait pattern. If we just lengthen the shortened muscle group without effective retraining, the gait pattern will not be corrected.
The Muscle Balance Theory explains that the altered muscle length affects function. Muscular imbalance leads to the chronic use of one muscle group, with a detriment to the others. Then the dominant muscle eventually loses functional length and/or extensibility. Lengthening the shortened muscles only depletes the effectiveness of the pathologic strategy. When not replaced with an alternate strategy, the established patterns continue and lead to recurrence of contractures and/or tightness. Treatment options to retrain the gait pattern include core strengthening and posterior load line training (walking on heels, standing with toes up an wedge or dowel to direct their weight backwards or performing squats). It is also important to teach hip and ankle co-activation for balance control. This can be accomplished by walking on a balance beam, standing on unstable surfaces, and sometimes playing Wii. In addition, working with the child in a staggered stance that is greater than the usual step length will increase the dynamic stability of the child. Neuromuscluar electrical stimulation has also been shown to increase the number of muscle fibers during a contraction, thus increasing strength. This does not require a high level of cognitive function to benefit the child, however can typically only be worked on in a clinical setting.
Sensory Processing Dysfunction can also lead to toe walking, which requires entirely different treatment techniques, including a sensory diet. Children with this disorder are typically either sensory seeking or sensory avoiding. “Sensory seeking” children often benefit from joint compressions, which will help for approximately 2 hours, as it gives the joints and ligaments more information to process where they are in space. Vestibular activities will also help for approx. 4-6 hours. “Sensory avoiding” children may state that walking with their feet flat on the floor feels like it is walking on hot sand. This is because of the heightened state of the tactile receptors in the soles of their feet. A brushing protocol or Kinesio tape will often benefit these children.
Prematurity is a good indicator that a child may toe walk. This is because, during the last four weeks of gestation, the human fetus is confined in a tight space, which decreases the amount of movement and promotes ankle flexion, thus lengthening the calf muscles. Those children that are born premature, have more space to move around, and don’t get this stretch on their calves, thus causing shorter muscles when they are born.
Other things to consider when a child toe walks include GI function and vision. A child with a lot of reflux or stomach pain may go into an exaggerated extensor pattern, which will bring them up on their toes.
There has also been research explaining two different types of visual fields. Focal vision is the central visual field and is independent of other body systems. Ambient vision is the entire visual field and is integrated with the other body systems. It has been found that most autistic children have a lack of attention to their ambient vision, giving decreased neurofeedback to the other body systems. This decreases their ability to process information in the areas involving speech, thought, posture and movement. Prisms are sometimes used to treat these kids as it alters their visual field and stimulates active reorganization of visual processing.
Treating toe walking is important because this altered position of gait changes all of the biomechanics of the skeletal system. It often causes impaired function, multiple joint pain, degenerative arthritis, knee instability, osteoarthritis, increased frequency of injury, and incompatibility with foot wear.