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.