Erica Essex, PT Student | Jimmy Crick, PT Student

1. In children diagnosed with idiopathic toe walking, is Physical Therapy and dynamic splinting better than surgical intervention in restoring normal gait mechanics? Erica Essex, PT Student | Jimmy Crick, PT Student Background Conservative Treatment Conclusion • PT with dynamic splinting and surgery are equally effective in normalizing gait in ITW’s • Surgery may be more effective with a fixed equinas contracture • Greater risk associated with surgery • Conservative treatment should be considered first • Further research is needed to : • - determine any residual negative issues caused by • prolonged abnormal gait in cases who spontaneously • resolve • Idiopathic toe walking (ITW) is a toe-toe gait pattern that persists after the age of 2 in a developmentally normal child.1,2 • Also referred to as habitual toe-walking or congenital short tendo calcaneus • Normal occurrence in children with developing gait (< age 2) • Theories of etiology include: • -Congenital shortening of tendo-calcaneus3 • -Hereditary trait (autosomal dominant pattern of • inheritance) 3 • -Mild spastic diplegia (with no neurological issues) 3 • ITW has been associated with: • -Family history of occurrence1,4 • -Concurrent speech/language delays1,3 • -Learning disabilities2,3 • ITW clinical presentation: • -Typical gait except bearing weight on forefoot 2,5 • -PROM for dorsiflexion exceeds amount necessary for • normal gait 2,5 • -Decreased extensibility of one or both triceps surea • muscles and/or heel cord 2,5 • -Normal neurologic exam 1,2,3,5 • Options include: Physical Therapy (PT), dynamic splinting/serial casting, night splinting, AFO’s, and botulinum toxin injections • Physical Therapy includes: gait retraining, passive plantar flexors stretching, dorsiflexors strengthening, and active plantar flexor exercises 2,7,8 • With 6 weeks of serial casting and PT, increased DF range and normal gait EMG restoration has been shown9 • With 4 months of PT and night splinting, normal gait restoration has been shown7 • With median of 6 weeks of casting, dramatic improvements in heel-toe gait have been shown1 • With serial casting, exercises alone, • or a combination of both, • increased DF and heel-toe • gait pattern have been improved 10 Clinical Relevance • Early PT is important • Dynamic splinting improves • outcomes with PT • Gait can normalize spontaneously • Potential future orthopedic problems: • - anterior pelvic tilt6 • -ER feet (theorized to be due to • either an ER tibia or ER femur • compensation)1,4,6 • -hindfoot valgus1 • -equinas contracture1,4,6 • May be an indicator of developmental problems -should be referred for a developmental assessment and PT2,3 http://chesapeakechildrenstherapycenter.wordpress.com/2013/08/26/toe-walking-and-physical-therapy/ http://www.alimed.com/alimed-pediatric-classic-night-splint.html Surgical Treatment • Surgical procedures for ITW include: 4,6 • - Vulpius: Gastroc recession proximal to • Achilles • - Tendo-Achilles Lengthening: Gastroc and • Soleus lengthening • - Baumann: proximal Gastroc lengthening • - Strayer: Gastroc lengthening at • musculotendinous junction • Surgery is recommended for: • - fixed equinas contractures4,5,6 • - non-responders to conservative • treatment 1,4 • Surgical outcomes are generally positive • Primary risk: residual weakening of ankle plantar flexors leading to a calcaneal gait pattern 1,4 http://www.foot-pain-explained.com/toe_walking.html References 1. Fox A, Deakin S. Serial casting in the treatment of idiopathic toe-walkers and review of the literature. Acta …. 2006;72(6):722–730. Available at: 2. Sala D a, Shulman LH, Kennedy RF, Grant a D, Chu ML. Idiopathic toe-walking: a review. Dev. Med. Child Neurol. 1999;41(12):846–8. 3. Shulman LH, Sala D a, Chu ML, McCaul PR, Sandler BJ. Developmental implications of idiopathic toe walking. J. Pediatr. 1997;130(4):541–6. 4. Peden S. Idiopathic Toe Walking. J. ICRU. 2009;9(2):NP. 5. Hirsch G, Wagner B. The natural history of idiopathic toe-walking: a long-term follow-up of fourteen conservatively treated children. ActaPaediatr. 2004;(93):196–200. 6. McMulkin ML, Baird GO, Caskey PM, Ferguson RL. Comprehensive outcomes of surgically treated idiopathic toe walkers. J. Pediatr. Orthop. 2006;26(5):606–11. 7. Lundequam P, Willis FB. Dynamic splinting home therapy for toe walking: a case report. Cases J. 2009;2:188. 8. Tachdjian M. The Child’s Foot. Philadelphia: WB Saunders; 1985. 9. Griffin PP, Wheelhouse WW, Shiavi R BW. Habitual Toe-Walkers. J. Bone Jt. Surg. 1977;59A:97–101. 10. Katz MM MS. Hereditary tendoAchillis contractures. J. Pediatr. Orthop. 1984;4:711–714. Peden S. Idiopathic Toe Walking. J. ICRU. 2009;9(2):NP.