toe walking physical therapy paper

Fifteen-minute consultation: A child with toe walking

Shobha Sivaramakrishnan,1 Arnab Seal2

1New Street Health Centre, Barnsley, UK 2Children’s Services, Leeds Community Healthcare Trust, Wortley Beck Health Centre, Leeds, UK

Correspondence to Dr Arnab Seal, Children’s Services, Leeds Community Healthcare Trust, Wortley Beck Health Centre, Ring Road, Leeds LS12 5SG, UK; [email protected]

Received 12 November 2014 Revised 14 February 2015 Accepted 4 March 2015

To cite: Sivaramakrishnan S, Seal A. Arch Dis Child Educ Pract Ed Published Online First: [please include Day Month Year] doi:10.1136/ archdischild-2014-307852

ABSTRACT 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 toe walking is a diagnosis of exclusion. Persistent toe walking can lead to limited ankle dorsiflexion which may cause functional problems. Specific interventions depend on underlying cause and may range from verbal reinforcement to serial casting and surgery.

TOE WALKING IN CHILDREN Toe walking is a gait abnormality charac- terised by absent heel strike and walking predominantly on the forefoot. It may be a normal developmental presentation under 2 years of age. Persistent toe walking, that is, lasting longer than 6 months after independent walking has been established, merits further evalu- ation for underlying neuromuscular or developmental problems.1 Cerebral palsy, Duchenne muscular dystrophy and autism may all initially present with per- sistent toe walking. Children without any underlying

medical condition who walk on their toes are referred to as idiopathic or habitual toe walkers (ITW). A study from Sweden reported a total prevalence of 4.9% of idiopathic toe walking and 2.1% of per- sistent toe walking in a cohort of 5.5-year-old children.2 In children who had a neuropsychiatric diagnosis or devel- opmental delay, the prevalence of a history of toe walking (inactive) and per- sistent toe walking (active) was 41.2%.2

A study in an orthopaedic clinic of per- sistent toe walkers without known devel- opmental problems showed significant association with language delay and motor delay.3

AETIOLOGY Toe walking is associated with a variety of pathological causes as outlined in table 1.

In general, diagnosis of ITW is one of exclusion and requires thorough physical examination and diagnostic work up where indicated. Several possible aetiologies have been postulated for ITW, such as defects in sensory processing, short tendo-achilles, different proportions of Type 1 muscle fibres, familial aetiology (often there is a positive family history) and others.4 6

ASSESSMENT The focus of assessment is to establish the degree of the problem (box 1) and determine the aetiology. These will help to decide appropriate management (see table 1).

HISTORY A routine paediatric history with a par- ticular reference to the following aspects: ▸ Detailed birth history, perinatal events,

gestation, developmental progress, family history of toe walking and neuromuscular disorders.

▸ Specific history regarding onset of toe walking, ability to walk with heel strike. Whether the planti-grade foot posturing was present before weight bearing. This may indicate spasticity or dystonia.

▸ History of any neuropathic bladder or bowel symptoms inappropriate for age, for example, dribbling of urine, faecal incontin- ence. These may indicate spinal disorders.

▸ History of language delay, intellectual dis- ability, disordered use of language and social skills. Toe walking has a high prevalence in autism and/or intellectual disability.

▸ History of any sensory processing pro- blems, for example, unusual response on minimal exposure to any sensory stimulus (hypersensitivity) or need for significantly more stimulus/sensory trigger for response (hyposensitivity).

▸ History of associated symptoms of lower limb pain, instability and any other func- tional problems.

▸ Assess the impact on the child and on parents.

BEST PRACTICE

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Table 1 Toe walking: aetiology, assessment and management

Aetiology Assessment features Management

Idiopathic/habitual Starts under 2 years of age as variation of normal, usually intermittent but then can persist. Can walk with heel strike when asked. May have positive family history. Normal neurology and orthopaedic examinations except some may have limited dorsiflexion. Diagnosis of exclusion of other causes. Can become persistent, especially over 3 years of age. Can resolve spontaneously up to 5 years of age.

Advise reminders of ‘heel down’. Usually will resolve. Idiopathic toe walking persisting over 3 years or causing functional problems or not getting heel strike at all due to high calf tone/ contractures: review whether the diagnosis is correct. If no evidence of other disease: ▸ Refer for physiotherapy assessment. ▸ Consider orthoses (footwear/splints), ▸ Serial casting (good evidence)4

▸ ±Botox injections to calf muscles (insufficient evidence)5

▸ Gait analysis or Tread Mat may be helpful4 6

▸ If poor or partial response, consider orthopaedic referral (usually after 5–7 years of age). Surgery helpful, especially if contractures present (good evidence)4

Brain lesions (UMN) Cerebral palsy (CP) Hydrocephalus UMN brain lesions

Any suggestive history of brain injury? Birth history: pre, peri or post natal risk factors Preterm with IVH or Extreme prematurity UMN signs: spasticity/dystonia, brisk deep tendon reflexes, clonus, extensor plantar reflex Large OFC: any signs of hydrocephalus?

Proceed to MRI brain and spine. If high risk factors for CP present, then likely to be CP. Approach to management of spasticity includes physical therapy, orthoses, pharmacological therapy (oral, injectable, intrathecal) and surgical approaches. Refer to National Institute for Clinical Excellence Clinical Guidance 1457

Spinal lesions Spina bifida: open and closed Tethered cord syndrome Spinal space occupying lesion

Lesions over spine/natal cleft deviation Sacral pits Spinal curves, especially in dysraphism UMN±LMN signs in lower limbs Bladder/bowel symptoms Back pain/tenderness

Abnormal spinal examination and/or history of progressive crouch gait with/without neuropathic bladder/bowel symptoms: likely to be spinal cause, for example, diastematomyelia. Initial investigation with MRI spine. Further evaluation may require other neuroimaging modalities. Refer to paediatric neurosurgeon if MRI suggests spinal dysraphism.

Peripheral neuropathy HMSN Peroneal neuropathy

Muscle wasting; ‘inverted champagne bottle’ in Charcot Marie Tooth variant of HMSN LMN signs: reduced reflexes; weakness of dorsiflexion; footdrop May have sensory loss (difficult to establish in young children) May have positive family history

Consider investigations for neuropathy and refer to paediatric neurologist. Biochemical tests, neuroimaging, electrophysiology, genetic studies and rarely nerve histology may be required

Muscle disorders Dystrophy, for example, Duchenne muscular dystrophy

Delayed motor milestones Hypotonia with reduced/absent reflexes Calf hypertrophy (DMD) May have positive family history

Consider muscle enzymes, electromyography and nerve conduction studies. Refer to paediatric neurology/neuromuscular service. Additional genetic studies, neurometabolic tests and muscle histology often needed.

Movement disorders Dopa sensitive dystonia Transient focal dystonia of infancy

May have unusual posture even prior to starting to walk. Often have dystonic posture at rest. May have variation: diurnal, tiredness, intercurrent illness. May have impaired speech. May masquerade as ‘cerebral palsy’ without risk factors for CP or as idiopathic toe walking

Perform a MRI brain and spine; if normal, consider trial of Dopa and seek paediatric neurology advice. Could be primary dystonia or dystonic CP. Note: Dopa sensitive dystonia can be hard to differentiate from idiopathic toe walking or dystonic CP. If in doubt, give a therapeutic trial of Dopa. Improvement is remarkable!

Developmental disorders Autism spectrum disorder Language disorders Intellectual disability Sensory processing disorders

Postulated to be behavioural or sensory problem but no conclusive evidence.8

Toe walking has been reported to be associated with: ASD, language disorders or sensory disorders in around 40% of children

If possible obtain a sensory processing profile of the child. Possible sensory problem: think of touch, pressure, position, joint sense. Think of texture/material of clothes/footwear, type of surface/ floor, pressure points. Think of patterns on floor. Assess when/where it happens. Touch avoidant? Prefers being bare feet? Try seamless socks. Whose problem? Parental embarrassment or definite functional problem, for example, won’t wear shoes?

Miscellaneous Short calf tendon/muscle Ankylosing spondylitis Calf muscle venous malformation Compensatory Local pain

Short tendon/muscles: no hypertonia in calf muscles but restricted range of dorsiflexion. Sometimes called ‘Short Tendocalcaneous’. Likely to be same entity or overlap with persistent idiopathic toe walking. Compensatory: for flexion deformity at knee or hip. If unilateral, could be compensatory for short limb.

Manage as idiopathic toe walking in ‘short tendocalcaneous’ group. Address primary problem causing functional limb length discrepancy in compensatory group.

DTR, deep tendon reflexes; LMN, lower motor neurone; UMN, upper motor neurone.

Best practice

2 Sivaramakrishnan S, et al. Arch Dis Child Educ Pract Ed 2015;0:1–4. doi:10.1136/archdischild-2014-307852

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PHYSICAL EXAMINATION ▸ Examination of gait pattern with/without orthoses (if

any), with/without shoes, with/without socks. Can the child walk with a heel strike? Is the child well co-ordinated when walking and/or running on toes? This would suggest ITW.

▸ General and musculo-skeletal examination. ▸ Developmental assessment. Look for any syndromic

associations, for example, dysmorphism. ▸ Perform detailed neurological examination including

muscle strength, tone, sensation, deep tendon reflexes and superficial reflexes (abdominal and plantar reflex). Consider cremasteric reflex and anal wink in spinal lesions.

▸ Spine examination: any curvature, cutaneous abnormal- ities, swellings or open pits over the spine.

▸ Lower limb examination for pelvic asymmetry, leg length discrepancy, muscle bulk and wasting. Particular atten- tion should be paid to detecting contractures and tone of hamstrings, calf muscles and range of movements at knee and ankle. A better range of ankle movement by flexing the knee may suggest short calf muscles. Check

for any deformities of ankle or foot. Many children who toe walk can retain normal dorsiflexion (10°–20° past neutral) but those with contractures have reduced range.

Williams et al9 developed the Toe walking Tool, a 28-item questionnaire to aid physicians in identifying the underlying condition that leads to a toe walking gait.

MANAGEMENT Management depends on which cause is identified from the history and assessment (see table 1).

Competing interests None.

Provenance and peer review Commissioned; externally peer reviewed.

REFERENCES 1 Oetgen ME, Pedan S. Idiopathic toe walking. J Am Acad

Orthop Surg 2012;20:292–300. 2 Engstrom P, Tedroff K. The prevelance and course of idiopathic

toe-walking in 5-year-old children. Pediatrics 2012;130:279–84.

3 Shulman LH, Sala DA, Chu ML, et al. Developmental implications of idiopathic toe walking. J Pediatr 1997;130:541–6.

4 Sala DA, Shulman LH, Kennedy RF, et al. Idiopathic toe walking: a review. Dev Med Child Neurol 1999;41:846–8.

5 Engelstrom P, Bartonek A, Tedroff K, et al. Botulinum toxin A does not improve the results of cast treatment for idiopathic toe walking: a randomised controlled trial. J Bone Joint Surg Am 2013;95:400–7.

6 Caselli MA. Habitual toe walking. Podiatr Manag 2002;21:163–70.

Box 1 Assessment of degree of problem

▸ Can the child voluntarily walk with heel strike when requested?

▸ Any tightness of tendo-achilles and calf muscles? ▸ Any weakness of ankle dorsiflexors? ▸ Any contractures? Any fixed limitation of

dorsiflexion? ▸ Establish range of movement with knee extended

and flexed. ▸ Is the problem at the ankle or is it compensatory for

hip and/or knee flexion deformity? ▸ Any functional effects? Pain, falls, instability, foot-

wear problems, embarrassment? ▸ Is the child actually experiencing any difficulty or is it

the parent/carer’s perception?

Test your knowledge

Toe walking in children: A. Over 3 years of age is usually a sign of a significant

underlying neuro-developmental problem. B. If persistent, should be treated with botulinum toxin

injections. C. Is commonly associated with language and/or motor

delay. D. Persisting over 3 years of age will usually resolve

spontaneously. Answers are at the end of the references

Key messages

▸ In children below 3 years of age who have no risk factors, have normal development, normal examin- ation, no contractures and where toe walking is a normal variation, parents need to be reassured that it is likely to resolve spontaneously.

▸ The vast majority of persistent toe walkers over 3 years of age are idiopathic toe walkers and have a good chance of spontaneous resolution by 5 years of age. Advise carers how they can help, what to look out for and when to contact services for intervention (see table 1). Provide ‘safety net’ advice regarding review needs which include persistence over 5 years of age, progressive tightening at ankle, evolving neurological signs or any functional problems.

▸ A good consultation involves spending time to explain the natural progression of the disorder and the likelihood that the condition will resolve spontan- eously. Providing written information using a parent information leaflet is recommended.

Best practice

Sivaramakrishnan S, et al. Arch Dis Child Educ Pract Ed 2015;0:1–4. doi:10.1136/archdischild-2014-307852 3

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7 Spasticity in children and young people with non-progressive brain disorders: Management of spasticity and co-existing motor disorders and their early musculoskeletal complications. NICE CG 145 Published July 2012. http://www.nice.org.uk/ guidance/cg145/

8 Williams CM, Tinley P, Curtin M. Idiopathic toe walking and sensory processing dysfunction. J Foot Ankle Res 2010;3:16.

9 Williams CM, Tinley P, Curtin M. The Toe Walking Tool: a novel method for assessing idiopathic toe walking children. Gait Posture 2010;32:508–11.

Answers to the multiple choice questions

(A) False; (B) False; (C) True; (D) True.

Best practice

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walking Fifteen-minute consultation: A child with toe

Shobha Sivaramakrishnan and Arnab Seal

published online April 8, 2015Arch Dis Child Educ Pract Ed

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