Toe Walking in Children. Do you know what you are dealing with ?
In the literature this condition typically has prompted thoughts of possible Autism-spectrum, possible CMT (Charcot-Marie Tooth Disease), CP (Cerebral Palsy), MD (Muscular Dystrophy). Those are ominous diagnoses to consider if you are a parent with a toe walking child. There will be long sleepless nights without answers. When these types of disorders can clearly be ruled out, a diagnosis of “Idiopathy Toe Walking” is claimed. But, the research in recent years has brought new light onto the issue and we wanted to use today’s blog post to be a brief introduction. We will be doing another post in the coming week to look more deeply into this clinical phenomenon, but today will just serve as an introduction to wet your palate and get your head in the right direction.
As you can see in this gait, nothing appears to be terribly abnormal in the foot structure (from what we can tell), the client is merely remaining in the plantarflexed posture and forefoot weight bearing. This is highly ineffective gait and can be very fatiguing let alone to mention the sustained loading into the posterior compartment and plantarflexor mechanism (gastrosoleus-achilles). And remember, the tibialis posterior and long toe flexors are close neighbors with capabilities of plantarflexion moments, so there are possible clinical manifestations there as well not to mention the obvious (especially to long-time Gait Guys readers) deficits that will be found in functional ankle dorsiflexion, ankle rocker and S.E.S. (skill, endurance, strength) of the anterior compartment mechanism (tibialis anterior, long toe extensors, peroneus tertius). Even if this client were to go into normal heel strike and stance phases right now, they would have lots of work to do to restore the anterior-posterior compartment balance, the 3 foot rockers (heel, ankle and forefoot) to avoid functional pathology.
Idiopathic toe walking is suggested to be as prevalent as 12%. Neuromotor maturation comes about via the suppression of the primitive reflexes/windows and appearance of the postural reflexes and responses. Delays or subtractions of these windows/reflexes may cause challenges in the normal development and maturation of the central and/or peripheral nervous systems. With toe walking, the clinical window most studies suggest is to begin investigation after 3 years of age when the primitive motor patterns should have solidified and the gait and postural patterns have begun to layer on top of those primitive reflexes. Remember though, the primitive patterns are not sequentially fixed, meaning that infants move in and out of these reflexes until they become permanent. It is not until they are fixed that the postural patterns, which are volitional, can be gradually built. This should bring some thoughts to your mind right now. Is toe walking behavior a missed primitive window or a non-volitional postural window? These kids are not doing this by choice, anyone who has worked with these types of cases knows this very well, and we have seen our share.
So what could be going on here ? Is this neurodevelopmental ? Yes, for sure. But where did things go awry ? And how do we fix it ? We will get into all of this next week but in the mean time remember that the development of primitive and postural reflexes is supposed to occur proximal to distal (ie. from core to hand/foot). This must be a motor-sensory deficit or mismatch, and we will go into that next week on the blog. In the meantime, consider the definition:
Idiopathic: Of unknown cause. Any disease that is of uncertain or unknown origin may be termed idiopathic.
That definition should only occur if further research does not render sufficient answers and theories. Next week we will propose some new ideas in the research up to 2014, ideas and proposals that will hopefully lead us to answers and dropping of “idiopathic” from this disorder.
Have a great day gait brethren !
Shawn and Ivo, The Gait Guys