Developmental implications of idiopathic toe walking

Assessing dynamic stability in children with idiopathic toe walking during overground walking

BACKGROUND

Children with idiopathic toe walking present with reduced ankle mobility, impaired balance, and difficulties in motor control. There is a need to diagnose idiopathic toe walking in a holistic manner and improve the monitoring of interventions. The aim is to assess dynamic stability with measures of margin of stability and whole-body angular momentum and evaluate their clinical relevance.

METHODS

A retrospective cross-sectional study with 35 idiopathic toe walkers (23 male, mean age (SD) 10.0 (2.9) years) and 20 typically developing controls (10 male, 11.4 (2.8) years). All participants had a clinical gait analysis at the local hospital. Dynamic stability was assessed with margin of stability, whole-body angular momentum, GaitSD, and spatiotemporal gait parameters. Student t-tests with adjustments for multiple comparisons were performed.

FINDINGS

Margin of stability in anterior direction was significantly shorter (ES = 1.29) and whole-body angular momentum in the coronal plane was significantly larger (ES = 0.90) in idiopathic toe walkers compared to typically developing children. No other results were below the set threshold for significance.

INTERPRETATION

Children with idiopathic toe walking continue to use an immature, falling forward movement strategy to maintain forward momentum. It is probable that those children adopted toe walking behavior to support increased energy absorption during the initial fall. Furthermore, the addition of dynamic stability measures not only provides insight into their ability to balance, these measures also allow an understanding of the plausible strategies adopted during walking and could potentially improve diagnosis and quantification of therapeutic outcomes.

A Pilot Study of Idiopathic Toe Walking: Measures and Outcomes

This pilot study sought to determine the feasibility of quantifying sensory processing, postural control, motor skill development and participation in daily life in children with idiopathic toe walking (ITW) compared to children without ITW. A nonrandomized, prospective case-control design was employed. Twenty participants were recruited. Computerized weight bearing and postural control data was successfully collected. Differences were found in forefoot/rearfoot weight bearing, balance, sensory-motor abilities and parent reported participation challenges. Sensory processing results were inconclusive. Findings can inform standardized assessment and treatment of ITW.

Predictive simulations identify potential neuromuscular contributors to idiopathic toe walking

BACKGROUND

Most cases of toe walking in children are idiopathic. We used pathology-specific neuromusculoskeletal predictive simulations to identify potential underlying neural and muscular mechanisms contributing to idiopathic toe walking.

METHODS

A musculotendon contracture was added to the ankle plantarflexors of a generic musculoskeletal model to represent a pathology-specific contracture model, matching the reduced ankle dorsiflexion range-of-motion in a cohort of children with idiopathic toe walking. This model was employed in a forward dynamic simulation controlled by reflexes and supraspinal drive, governed by a multi-objective cost function to predict gait patterns with the contracture model. We validated the predicted gait using experimental gait data from children with idiopathic toe walking with ankle contracture, by calculating the root mean square errors averaged over all biomechanical variables.

FINDINGS

A predictive simulation with the pathology-specific model with contracture approached experimental ITW data (root mean square error = 1.37SD). Gastrocnemius activation was doubled from typical gait simulations, but lacked a peak in early stance as present in electromyography. This synthesised idiopathic toe walking was more costly for all cost function criteria than typical gait simulation. Also, it employed a different neural control strategy, with increased length- and velocity-based reflex gains to the plantarflexors in early stance and swing than typical gait simulations.

INTERPRETATION

The simulations provide insights into how a musculotendon contracture combined with altered neural control could contribute to idiopathic toe walking. Insights into these neuromuscular mechanisms could guide future computational and experimental studies to gain improved insight into the cause of idiopathic toe walking.

Assessing sensory processing differences in children with idiopathic toe walking: A pilot study

Idiopathic toe-walking (ITW) refers to persistent walking without heel contact for unknown reasons. An underexplored area is the relationship of sensory processing to ITW. This study presents methods to assess sensory differences in individuals with ITW and summarizes results from a pilot testing of the measures. This pilot study included nine children and one young adult with ITW. Ten age-matched controls were recruited to provide a comparison group when norms were not available in the literature. The measures included in this study were as follows: sensory questionnaires; electrodermal activity response to sensory stimuli; monofilaments; biothesiometer; gait on different surfaces; NeuroCom® SMART Balance Master® Sensory Organization Test and Adaptation Test; and ankle position matching. All study procedures were completed in about 3 hours. Children as young as 4 years were able to complete the measures. We observed overall differences in sensory processing, specifically, higher Sensory Processing Measure scores (p = .011), higher resting electrodermal activity (p = .012), increases in heel-toe walking on novel surfaces (p = .034), and more falls with balance perturbation (p = .007) in individuals with ITW. A subset of individuals also showed tactile hyposensitivity (5 out of 10 in the ITW group) and poor equilibrium scores in the Sensory Organization Test (4 out of 9 in the ITW group, 1 unable to complete the test). Our results confirmed the heterogeneity in the etiology of ITW. We propose that further testing in sensory modulation, tactile processing, and vestibular processing is needed to fully explore the impact of sensory processing on children with ITW.

Gut Microbiome Dysbiosis as a Potential Risk Factor for Idiopathic Toe-Walking in Children: A Review

Idiopathic toe walking (ITW) occurs in about 5% of children. Orthopedic treatment of ITW is complicated by the lack of a known etiology. Only half of the conservative and surgical methods of treatment give a stable positive result of normalizing gait. Available data indicate that the disease is heterogeneous and multifactorial. Recently, some children with ITW have been found to have genetic variants of mutations that can lead to the development of toe walking. At the same time, some children show sensorimotor impairment, but these studies are very limited. Sensorimotor dysfunction could potentially arise from an imbalanced production of neurotransmitters that play a crucial role in motor control. Using the data obtained in the studies of several pathologies manifested by the association of sensory-motor dysfunction and intestinal dysbiosis, we attempt to substantiate the notion that malfunction of neurotransmitter production is caused by the imbalance of gut microbiota metabolites as a result of dysbiosis. This review delves into the exciting possibility of a connection between variations in the microbiome and ITW. The purpose of this review is to establish a strong theoretical foundation and highlight the benefits of further exploring the possible connection between alterations in the microbiome and TW for further studies of ITW etiology.

NGS-Panel Diagnosis Developed for the Differential Diagnosis of Idiopathic Toe Walking and Its Application for the Investigation of Possible Genetic Causes for the Gait Anomaly

Idiopathic toe walking (ITW) describes a condition affecting approximately 4.5% of children. Toe walking is an accompanying symptom for many hereditary disorders. This retrospective study uses next-generation sequencing-panel-diagnosis to investigate the feasibility of genetic testing to research the possible genetic causes of ITW and for differential diagnosis. Data were taken from our inhouse database, the minimum age for participants was 3 years. Underlying neurological or orthopaedic conditions were tested for and ruled out prior to diagnosing ITW. Patients, who experienced complications before, during or immediately after birth, children with autism, and patients toe walking less than 50% of the time were excluded. Eighty-nine patients were included in the study, in which 66 (74.2%) patients were boys and 23 (25.8%) girls. Mean age at testing was 7.7 years (range: 3-17 years). Fifteen of the 89 patients included in the study (16.9%) had a genetic variant identified as likely pathogenic or pathogenic by the genetics laboratory. Additionally, we found 129 variants of uncertain significance. About 65.2% of patients showed a pes cavus foot deformity, 27% of patients reportedly had at least one relative who also displayed the gait anomaly, and 37.1% had problems with their speech development. Despite the limitations of the sample size and the scope of our genetic testing targets, our results indicate that research into the genetic causes of ITW could better our understanding of the causes of ITW in otherwise healthy children, to help develop novel methods to detect serious conditions early. ITW could be an early onset symptom for further hereditary conditions.

Idiopathic Toe-Walking: A Review from 1967 to 2021

Idiopathic toe-walking (ITW) is considered a diagnosis of exclusion for which no underlying neurological, neuromuscular, neurodevelopmental, or orthopedic condition can be identified. The purpose of this review was to examine multiple aspects of ITW: natural history, evaluation, treatment, musculoskeletal manifestations, and developmental issues through the review of studies from the initial description of condition in 1967 to the present. From a PubMed search and review of reference lists of individual articles, 64 articles were selected and reviewed. The studied samples were variably described and often not well-defined. Gait analysis found gait characteristics associated with ITW that varied from normal. Children with ITW can be differentiated from children with cerebral palsy on the basis of several gait pattern features, but findings from electromyographic comparisons were variable. Treatments included orthoses, casting, botulinum toxin type A, and surgery. The evidence to support any specific treatment is limited by the small sample size and short duration of follow-up in the majority of studies. The inadequacy of the current literature suggests the need for a longitudinal multi-center study to more clearly define the population of children with ITW and to determine indications, timing, and effectiveness of the various available treatments.

Kinematic and Kinetic Gait Parameters Can Distinguish between Idiopathic and Neurologic Toe-Walking

The differentiation between mild forms of toe-walking (equinus) in cerebral palsy (CP) and idiopathic toe-walking (ITW) is often clinically challenging. This study aims to define kinematic and kinetic parameters using 3D gait analysis to facilitate and secure the diagnosis of “idiopathic toe-walking”. We conducted a retrospective controlled stratified cohort study. 12 toe-walking subjects per group diagnosed as ITW or CP were included and stratified according to age, gender and maximal dorsiflexion in stance. We collected kinematic and kinetic data using a three-dimensional optical motion analysis system with integrated floor force plates. Pairwise comparison between ITW and CP gait data was performed, and discriminant factor analysis was conducted. Both groups were compared with typically developing peers (TD). We found kinematic and kinetic parameters having a high discriminatory power and sensitivity to distinguish between ITW and CP groups (e.g., knee angle at initial contact (91% sensitivity, 73% specificity) and foot progression angle at midstance (82% sensitivity, 73% specificity)). The strength of this study is a high discriminatory power between ITW and CP toe-walking groups. Described kinematic parameters are easy to examine even without high-tech equipment; therefore, it is directly transferable to everyday praxis.

The Effectiveness of Serial Casting and Ankle Foot Orthoses in Treating Toe Walking in Children With Autism Spectrum Disorder

PURPOSE

This proof of concept study examined the effectiveness of serial casting (SC) and ankle foot orthoses (AFOs) in children with autism spectrum disorder (Ch-ASD) who toe walk (TW). Data collected determined effects of SC, followed by AFO intervention on ankle dorsiflexion (A-DF) passive range of motion and kinematics, and parent-reported functional outcomes for children with autism spectrum disorder who TW and have limited A-DF passive range of motion.

SUMMARY OF KEY POINTS

The 5 participants increased passive range of motion with SC, except for 1 participant's left ankle. Two of 4 participants had near typical A-DF kinematic patterns following SC. The 5 participants improved A-DF during walking following 6 months of AFO use.

CONCLUSIONS

Serial casting increased A-DF ROM and kinematics during walking. Consistent AFO use for walking training improved function and reduced toe walking. Serial casting followed by AFOs is a potential intervention for children with autism spectrum disorder who TW.

Surgical Outcomes for Severe Idiopathic Toe Walkers

BACKGROUND

Idiopathic toe walking (ITW) is a diagnosis of exclusion and represents a spectrum of severity. Treatment for ITW includes observation and a variety of conservative treatment methods, with surgical intervention often reserved for severe cases. Previous studies reviewing treatment outcomes are often difficult to interpret secondary to a mixture of case severity. The goal of this study was to review surgical outcomes in patients with severe ITW who had failed prior conservative treatment, as well as determine differences in outcomes based on the type of surgery performed.

METHODS

After IRB approval, all patients with surgical management of severe ITW at a single institution were identified. Zone II or zone III plantar flexor lengthenings were performed in all subjects. Clinical, radiographic, and motion analysis data were collected preoperatively and at 1 year following surgery.

RESULTS

Twenty-six patients (46 extremities) with a diagnosis of severe ITW from 2002 to 2017 were included. Zone II lengthenings were performed in 25 extremities (mean age=9.9 y) and zone III lengthenings were performed in 21 extremities (mean age=8.6 y). At the most recent follow-up, 100% of zone III lengthening extremities and 88% of zone II lengthening demonstrated decreased severity of ITW. Six extremities required additional treatment, all of which were initially managed with zone II lengthenings.

CONCLUSIONS

Severe ITW or ITW that has not responded to conservative treatment may benefit from surgical intervention. More successful outcomes, including continued resolution of toe walking, were observed in subjects treated with zone III lengthenings.

LEVEL OF EVIDENCE

Level III-case series.

A Retrospective Analysis of Nonoperative Treatment Techniques for Idiopathic Toe Walking in Children: Outcomes and Predictors of Success

BACKGROUND

The lack of consensus regarding optimal nonoperative management of idiopathic toe walking (ITW) results in wide variation in treatment across providers and institutions. Untreated toe walking can cause persistence of abnormal gait and symptomatic foot deformity in adulthood.

OBJECTIVE

To examine the outcomes of multiple commonly used nonoperative treatment techniques in a large cohort of children with ITW to better inform management of this condition.

DESIGN

Retrospective cohort study.

SETTING

Single tertiary care children's hospital from 2008 to 2015.

PATIENTS

Two hundred four children with ITW, aged 4 to 7 years at time of diagnosis, nonoperatively managed in orthopedic surgery, rehabilitation medicine, neurodevelopmental medicine, neurology, or physical therapy clinics.

INTERVENTIONS

Nonoperative techniques included observation, home stretching program, physical therapy program, use of ankle-foot orthoses (AFOs), and serial casting.

MAIN OUTCOME MEASURES

Greater than or equal to 10° of ankle dorsiflexion with the knee extended or walking on toes less than 25% of the time at last visit. Failure of treatment was defined as not achieving resolution criteria or requiring surgical intervention following failed nonoperative management.

RESULTS

Only 121 children (59.3%) attended at least one follow-up visit. Of those, 55 (45.5%) had a successful outcome. Increasing severity of ITW was associated with increased rate of follow-up (P = .03) and lower rates of successful treatment (P = .03). The use of AFOs was the only treatment modality associated with a successful outcome (unadjusted/adjusted odds ratio 3.97; [95% confidence interval, 1.80-8.74] and 4.81 [95% confidence interval, 1.91-12.1], respectively; P = .001).

CONCLUSIONS

Loss to follow-up is common in children with ITW. Of those children who returned to clinic, less than half had a successful outcome. The only treatment technique statistically associated with short-term resolution of toe walking was the use of AFOs.

Reliability of a New Clinical Gait Assessment Scale for Children with Idiopathic Toe Walking Gait - A Pilot Study

AIMS

Children with idiopathic toe walking (ITW) gait are increasingly referred to physical therapists. The purpose of this study was to evaluate the intra-rater and inter-rater reliability of the Clinical Gait Assessment Scale (CGAS), a newly developed observational rating scale.

METHODS

Four raters evaluated videos of four children. Foot, arm and head/trunk movement was scored as children walked over four surfaces. Intra-class correlation coefficients (ICC), model (3,k) were calculated to determine intra-rater and inter-rater reliability of each dependent variable.

RESULTS

The key findings of this study indicate robust intra- and inter-rater reliability, particularly of the foot (Inter-rater reliability, ICC (3,2)=0.9) and head and trunk (Inter-rater reliability, ICC (3,2)=1.0) subsections. Arm movements were more challenging to rate and showed moderate reliability (Inter-rater reliability, ICC (3,2)=0.7). Highest total impairment score; the highest value occurred while walking on the obstacle course (38 ± 29).

CONCLUSIONS

Overall, the CGAS showed adequate/acceptable reliability across different surfaces (linoleum, textured surface, narrow base, obstacle), however the obstacle surface was most challenging surface to the rater.

Interventions for idiopathic toe walking

BACKGROUND

Idiopathic toe walking (ITW) is an exclusionary diagnosis given to healthy children who persist in walking on their toes after they should typically have achieved a heel-toe gait. The literature discusses conservative and surgical interventions using a variety of treatment modalities. Young children and children without a limitation in ankle dorsiflexion (the upwards movement of the foot towards the shin of the leg) are commonly treated with conservative interventions. Older children who continue toe walking and present with limitations in ankle dorsiflexion are sometimes treated with surgical procedures. This systematic review is needed to evaluate the evidence for any intervention for the treatment of ITW. The conclusions of this review may support decision making by clinicians caring for children with ITW. It may also assist families when deciding on treatment options for their children with ITW. Many of the treatments employed have financial implications for parents or healthcare services. This review also aims to highlight any deficits in the current research base.

OBJECTIVES

To assess the effects of conservative and surgical interventions in children with ITW, specifically effects on gait normalisation, ankle range of motion, pain, frequency of recurrence, and any adverse effects.

SEARCH METHODS

On 29 April 2019, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL Plus, and PEDro. We searched the following registers of clinical trials for ongoing and recently completed trials: the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP, apps.who.int/trialsearch), and ClinicalTrials.gov (clinicaltrials.gov). We searched conference proceedings and other grey literature in the BIOSIS databases and System for Information on Grey Literature in Europe (OpenGrey, opengrey.eu). We searched guidelines via the Turning Research Into Practice database (TRIP, tripdatabase.com) and National Guideline Clearinghouse (guideline.gov). We did not apply language restrictions.

SELECTION CRITERIA

We considered randomised or quasi-randomised trials for inclusion in the review if they involved participants diagnosed with ITW gait in the absence of a medical condition known to cause toe walking, or associated with toe walking. As there is no universally accepted age group for ITW, this review includes ITW at any age, who have been toe walking for more than six months, who can or cannot walk with a heel-toe gait, and who may or may not have limited dorsiflexion of the ankle joint.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. The primary outcome was improvement in toe walking (defined as greater than 50% of time spent heel-toe walking). Secondary outcomes were active and passive range of motion of the ankle joint, pain, recurrence of ITW after treatment, and adverse events. We assessed the certainty of the evidence using the GRADE framework.

MAIN RESULTS

Four studies, comprising 104 participants, met the inclusion criteria. One study did not report data within the appropriate follow-up timeframe and data from two studies were insufficient for analysis. The single study from which we extracted data had 47 participants and was a randomised, controlled, parallel-group trial conducted in Sweden. It tested the hypothesis that combined treatment with serial casting and botulinum toxin type A (BTX) was more effective than serial casting alone in reducing ITW gait.This study found that more participants treated with BTX improved (defined as toe walking less than 50% of the time, as reported by parents) (risk ratio (RR) 1.21, 95% confidence interval (CI) 0.57 to 2.55; 1 trial, 46 participants; very low-certainty evidence). However, there was little or no difference between groups in passive ankle joint dorsiflexion range of movement on the right with the knee extended (mean difference (MD) -1.48º, 95% CI -4.13 to 1.16; 1 trial, 47 participants), on the right with the knee flexed (MD -0.04º, 95% CI -1.80 to 1.73; 1 trial, 46 participants), on the left with the knee flexed (MD 1.07, 95% CI -1.22 to 3.37), or on the left with the knee extended (MD 0.05, 95% CI -0.91 to 1.91). Nor was there a clear difference between the groups in recurrence of toe-walking gait (assessed via severity of toe walking (graded 1 (mild), 2 (moderate), or 3 (severe)) on gait analysis, analysed as continuous data: MD 0.34 points, 95% CI -0.09 to 0.78; 46 participants). In principle, MDs greater than zero (i.e.) positive values) would favour BTX and casting and negative values would favour casting alone. We have not reported effects as better or worse because all results were from evidence of very low certainty. We downgraded the certainty of evidence because of study limitations (outcome assessment was not blinded) and imprecision. Outcomes of pain and active range of motion were not reported in the included study.In terms of adverse events, calf pain was reported twice in the casting-only group and three times in the BTX group. There were three minor skin problems in each group and one reported case of pain directly after BTX injection. The report did not state if calf pain and skin irritation were from the same or different participants. The study authors reported that adverse events did not alter treatment adherence.

AUTHORS' CONCLUSIONS

The certainty of evidence from one study, which compared serial casting with serial casting with BTX for ITW in children, was too low for conclusions to be drawn. A further three studies reported outcomes relating to BTX, footwear, exercises, and different types of orthoses as interventions, however the outcome data were too limited to assess their effects.

Full length foot orthoses have an immediate treatment effect and modify gait of children with idiopathic toe walking

BACKGROUND

There remains a substantial lack of evidence to support the use of foot orthoses as a conservative treatment option for idiopathic toe walking (ITW). Encouraging heel contact during gait is one of the primary goals of most interventions in paediatric ITW.

RESEARCH QUESTION

Does the combined treatment of high-top boots and orthoses increase the number of heel contacts during gait and change spatio-temporal gait parameters?

METHODS

This within subject designed randomised controlled trial recruited fifteen children diagnosed with ITW (n = 10 males). They were fitted with bilateral custom made rigid contoured carbon fibre foot orthoses placed inside high-top boots. To analyze the effect of this treatment, heel contacts and spatio-temporal parameters measured by an 8.3 m Gaitrite® mat were compared to barefoot walking and shod walking.

RESULTS

An immediate increase in heel contact (p = 0.021) was observed in the combined treatment only. Gait changes included a large increase in stride time in the combined treatment condition compared to barefoot walking (p = 0.006). This was associated with a decrease in the percentage of swing phase in the gait cycle (p < 0.010), an increase in stance phase (p < 0.010) and an increase in double support time (p < 0.001).

SIGNIFICANCE

These results suggest the hardness and thickness of the shoe and stiffness of the orthosis midsole may lead to improved local dynamic stability and foot position awareness with increased sensory feedback provided through the entire length of the foot. Further research is indicated to validate this treatment option on long term outcomes in this population group.

Outcomes of Noninvasively Treated Idiopathic Toe Walkers

Idiopathic toe walking (ITW) causes a common problem in pediatric orthopaedics. In the literature, numerous treatment options have been reported, but consensus about the management of ITW is still missing. The aim of the current study was to evaluate conservative treatment with pyramidal insoles. A total of 193 patients underwent conservative treatment between January 2010 and June 2013. Mean age at the beginning of the treatment was 7.75 ± 0.23 years (range 2.0-17.0 years). For all patients, demographic data, comorbid diseases, passive range of motion (ROM), persistent toe walking, and performed operations were retrospectively evaluated. Following operative treatment was defined failure. Eight (4.15%) patients underwent Achilles tendon lengthening operation after mean therapy time of 2.72 years (range 0.1-7.0 years), 174 cases were treated successfully (90.16%). In 50 cases, toe walking suspended completely after mean therapy time of 2.83 years. In cases of failure, patients were older at diagnosis and at the beginning of the treatment. Mean passive ROM increased over the time. In cases of failure, ROM decreased from the first to the second examination. Conservative treatment of ITW using pyramidal insoles can be effective. Ankle dorsiflexion significantly improved in the patients who were successfully treated. Therapy should start early. A decrease of ROM under therapy should lead to critical revisal of individual therapy. Levels of Evidence: Therapeutic, level IV: Case series.

McArdle's disease: A differential diagnosis of idiopathic toe walking

Idiopathic toe walking (ITW) is a pathological gait pattern in which children walk on their tip toes with no orthopedic or neurological reason. Physiological characteristics of the gastrocnemius muscles, the Achilles tendon, and the foot of toe walkers differ from subjects with a plantigrade walking pattern. McArdle's disease is characterized by the inability to break down muscle glycogen. It is an autosomal-recessive condition, characterized by low exercise tolerance, muscular atrophy at the shoulder girdle, episodes of myoglobinuria after vigorous physical activities and the occurrence of the second wind phenomenon. The aim of this review is to present the case studies of two subjects who were originally diagnosed as idiopathic toe walkers, but were then found to have McArdle's disease. This review will describe some physical characteristics that distinguish McArdle´s disease from Idiopathic toe walkers.

Idiopathic Toe-Walking: Prevalence and Natural History from Birth to Ten Years of Age

BACKGROUND

Children with idiopathic toe-walking, a common pediatric condition, walk some or all of the time on their toes. This condition often causes parental concern, with repeated medical contacts and a range of interventions including stretching, casts, injection of botulinum toxin A, and surgical procedures. The purpose of this cohort study was to document the natural history of this condition.

METHODS

In a population-based cohort of 1,401 healthy 5.5-year-old Swedish children, we found the prevalence of idiopathic toe-walking to be approximately 5% (63 of 1,401). Of the 63 children who had ever been a toe-walker, 26 still were at the age of 5.5 years and were followed in the current study at 8 and 10 years of age. At the 8-year follow-up, parents were asked by telephone whether their child had received any treatment or diagnosis since the 5.5-year assessment, as well as to what extent (approximately 25%, 50%, 75%, or 100% of the time) the child still walked on the toes. At the visit when the children were 10 years of age, their parents were asked the same questions. All 26 children also underwent a neurological examination and an orthopaedic examination focusing on the lower extremities.

RESULTS

At 8 years of age, 6 of 26 children had ceased toe-walking, and by the age of 10 years, 50 (79%) of the original 63 patients had spontaneously ceased toe-walking. Idiopathic toe-walking did not result in contractures of the triceps surae. One subgroup of children displayed early contracture of the ankle and should thus not be considered idiopathic toe-walkers. Four of the children who still toe-walked at the age of 10 years demonstrated some neurodevelopmental comorbidity.

CONCLUSIONS

By the age of 10 years, 79% of the children who have ever been a toe-walker spontaneously develop a typical gait, without intervention or contractures of the ankle dorsiflexion. The diagnosis of short tendo Achilles should be retained as a separate diagnosis as there is a subset of children with this entity who should be treated early in childhood. Neurodevelopmental comorbidities are common among those who continue to toe-walk.

LEVEL OF EVIDENCE

Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Soleus H-Reflex and Its Modulation With Vibration in Idiopathic Toe Walkers and Typically Developing Children

Idiopathic toe walking is a relatively common developmental condition often leading to secondary problems such as pain and muscle contractures in the lower extremities. The cause of idiopathic toe walking is unknown, which hinders the development of treatment strategies. To test whether children with idiopathic toe walking have functional alterations in their spinal motor circuits, we studied the properties of the soleus H-reflex and its modulation with vibration in 26 idiopathic toe walkers and 16 typically developing children. At the group level, the H-reflex properties did not differ, but at the individual level, in 7 of 25 idiopathic toe walkers, some of the H-reflex parameters fell out of normal limits of typically developing children. However, the H-reflex was suppressed by vibration to the Achilles tendon similarly in both the idiopathic toe walkers and typically developing children. In conclusion, idiopathic toe walking in some children can be associated with functional alterations in their spinal motor circuits.

Toe Walking: A Neurological Perspective After Referral From Pediatric Orthopaedic Surgeons

BACKGROUND

Toe walking (TW) in children is often idiopathic in origin. Our purpose was to determine the incidence of a neurological etiology for TW in patients seen in the neurology clinic after referral from pediatric orthopaedic surgeons.

METHODS

We performed an Institutional Review Board approved retrospective review of 174 patients referred to the neurology clinic from orthopaedic surgeons at an academic pediatric tertiary care center between January 2010 and September 2015. Medical records were reviewed and data recorded including pertinent family history, birth history, age of initial ambulation, physical examination findings, and workup results including neuroimaging, neurophysiological studies, and findings of genetic testing and tissue biopsy.

RESULTS

Sixty-two percent (108/174) of patients were found to have a neurological etiology for TW. Final pathologic diagnoses were: 37% (40/108) previously undiagnosed cerebral palsy (CP), 16.7% (18/108) peripheral neuropathy, 15.7% (17/108) autism spectrum disorder, 13.9% (15/108) hereditary spastic paraparesis, 8.3% (9/108) attention deficit hyperactivity disorder, 5.6% (6/108) syndromic diagnosis, and 2.8% (3/108) spinal cord abnormality. Ankle equinus contractures were noted in idiopathic and neurological patients and did not indicate a pathologic origin. Seventy-one percent of unilateral toe walkers and 32% of bilateral but asymmetric toe walkers were diagnosed with CP (P<0.001). Twenty-six percent of 145 brain magnetic resonance imaging studies diagnosed CP. Of the 125 (72%) with spinal imaging, 3 had spinal pathology to account for TW. Fourteen percent of 87 subjects with an electromyography/nerve conduction study had abnormal results indicating a peripheral polyneuropathy.

CONCLUSIONS

An underlying pathologic diagnosis was found in 62% of patients referred to neurology for TW. A concerning birth history, delayed initial ambulation, unilateral TW, upper or lower motor neuron signs on examination, or behavioral features may suggest a pathologic diagnosis. Ankle contracture is not predictive of an abnormal diagnosis and can be found in idiopathic patients. CP, peripheral neuropathy, autism spectrum disorder, and hereditary spastic paraparesis are the most common pathologic diagnoses identified in our population.

LEVEL OF EVIDENCE

Level III-retrospective cohort.

The effect of persistent toe walking on the skeletal development of the pediatric foot and ankle

The aim of this study was to determine whether persistent idiopathic toe walking leads to compensatory skeletal changes in the pediatric foot and ankle. Foot radiographs of children diagnosed with idiopathic toe walking and sex-matched and age-matched controls were retrospectively reviewed. Five blinded providers assessed the foot radiographs for skeletal changes to the ankle. The relationship between each measure and toe-walking status was examined. Providers observed radiographic evidence of skeletal changes of the talus in idiopathic toe walkers compared with controls, suggesting that persistent toe walking impacts the skeletal development of the talus.

LEVEL OF EVIDENCE

prognostic level III.

[Do children with attention deficit and hyperactivity disorder (ADHD) have a diferent gait pattern? Relationship between idiopathic toe-walking and ADHD]

INTRODUCTION

Idiopathic toe-walking (ITW) is described as a gait pattern with no contact between the heels and the ground in children older than 3years. The diagnosis is clinical, making it necessary to rule out other neurological and orthopaedic conditions. A relationship between ITW and vestibular dysfunction and/or proprioceptive sensibility has been proposed. Children with neurodevelopmental disorders (autism, language and cognitive disorders) often have ITW.

OBJECTIVES

To determine the frequency of ITW in children with attention deficit disorder and hyperactivity (ADHD).

PATIENTS AND METHOD

A study was conducted on children diagnosed with ADHD, with normal neurological examination, with no alterations in MRI scan, cognitive disorder or autism. A complete clinical anamnesis was performed and Achilles shortening was measured with a goniometer.

RESULTS

The study included 312 children with a mean age of 11 years (73.7% boys). The ADHD combined subtype was the most frequent (53.8%), followed by the inattentive (44.9%), and hyperactive (1.3%). ITW was observed in 20.8% of patients, particularly in the combined subtype (P=.054). Only 32 of them (49.2%) had Achilles shortening. ITW was associated with sociability disorders (P=.01), absence of pain in legs (P=.022), and family history of ITW (P=.004). Only 11% had previously visited a doctor for this reason.

CONCLUSIONS

As in other neurodevelopmental disorders, children with ADHD have frequently more ITW and Achilles shortening than controls, especially if they presented with a social communication disorder or a family history of ITW. An early diagnosis is essential to establish effective treatments.

Idiopathic Toe Walking: Family Predisposition and Gender Distribution

Current literature is inconsistent concerning the causes and the frequency of idiopathic toe walking (ITW). Available studies vary widely in their results. The aim of this study is to supply gender-related data particularly regarding the genetic influence on toe walking. Methods The ITW patterns of 836 children were recorded and analyzed during a period of 4 years. Questionnaires and clinical measurements were evaluated along with clinical tests, assessing the occurrence and severity of toe walking. Information about the incidence of toe-walkers in the family was recorded. Results Of the 836 toe-walkers, 64% were boys and 42% had a positive family history (PF-TW). About 60% of the PF-TW children had fathers with a positive toe-walking pattern. PF-TW children were on average half a year younger than children with a negative family predisposition (NF-TW). Conclusions This study shows that a genetic component might be factor in toe walking. PF-TW children were more severely affected in all performed clinical tests than NF-TW children.

LEVELS OF EVIDENCE

Prognostic, Level IV.

Neurodevelopment in preschool idiopathic toe-walkers

INTRODUCTION

Idiopathic toe walking, a differential diagnosis for neurological and orthopaedic disorders, has been associated with neurodevelopmental alterations. Neurodevelopmental assessment at early ages using specific tests may improve management and follow-up of these patients. The aim of our study is to analyse the neurodevelopmental characteristics of preschool idiopathic toe-walkers (ITW) by comparing them to a control group.

METHOD

Our descriptive cross-sectional study compared possible risk factors, neurodevelopmental characteristics, and scores on the Child Neuropsychological Maturity Questionnaire (CUMANIN) between a group of 56 ITWs aged 3 to 6 and a control group including 40 children.

RESULTS

The proportion of males was significantly higher in the ITW group (P=.008). The percentage of patients with a family history (P=.000) and biological risk factors during the perinatal period (P=.032) was also higher in this group. According to the parents' reports, motor coordination in ITWs was significantly poorer (59%; P=.009). ITWs scored significantly lower on CUMANIN subscales of psychomotricity (=0,001) and memory (P=.001), as well as in verbal development (P=.000), non-verbal development (P=.026), and overall development (P=.004). Foot preference was less marked in the ITW group (P=.047).

CONCLUSIONS

The neurodevelopmental characteristics of our sample suggest that idiopathic toe walking is a marker of neurodevelopmental impairment. However, further studies are necessary to confirm these findings.

A Comparison of the Birth Characteristics of Idiopathic Toe Walking and Toe Walking Gait Due to Medical Reasons

OBJECTIVE

To determine and compare the birth history or postnatal complications of idiopathic toe walking (ITW) and toe walking known to be associated with a medical condition.

STUDY DESIGN

This was a retrospective chart review of parent-reported birth histories of children who presented to a dedicated toe-walking clinic between 2010 and 2014. This cohort comprised children diagnosed with ITW and children with a medical reason for their toe-walking gait. Data were compared with Australian Perinatal statistical normative data.

RESULTS

Ninety-five children (60 males, 63%) were diagnosed with ITW, with a mean (SD) age of 5.8 (2.9) years. Children with an ITW gait were found to have greater rates of prematurity (OR 2.4; 95% CI 1.43-4.03), greater rates of admission to a special care nursery or neonatal intensive care unit (OR 1.98; 95% CI 1.23-3.18), and lower birth weights (OR 6.6; 95% CI 3.48-12.5) than the normative population. Children with a medical reason for toe walking (n = 28, 68% males) also had greater rates of prematurity (OR 2.4; 95% CI 0.94-6.09) than the normative population and more instrumented births than the ITW cohort (OR 1.56; 95% CI 0.64-3.77). No association was found between assisted-birth intervention and the ITW cohort compared with the normative population or group with a medical cause for toe walking.

CONCLUSIONS

ITW gait was associated with greater rates of complications during and after delivery. Such complications have been associated previously as risk factors for neurologic insult affecting motor development.

A comparison of orthoses in the treatment of idiopathic toe walking: A randomized controlled trial

BACKGROUND

Orthotic treatment of idiopathic toe walking is complicated by the lack of a known etiology. This study compared control of toe walking using an articulated ankle-foot orthosis versus a rigid carbon fiber footplate attached to a foot orthosis.

OBJECTIVES

Ascertain differences between two orthoses in the control of idiopathic toe walking.

STUDY DESIGN

Randomized controlled trial.

METHODS

A total of 18 children with idiopathic toe walking were randomized to either the ankle-foot orthosis or foot orthosis treatment group in a Parallel Randomized Controlled Trial with no blinding. Prior to and after 6 weeks of treatment, participants completed three-dimensional gait assessment and the L-test of Functional Mobility. Parents completed a satisfaction survey and a subset of the Orthotic and Prosthetic User Survey after treatment.

RESULTS

Nine participants were analyzed in each group. Both groups showed significant improvement in kinematics versus baseline with orthoses; however, when the orthoses were removed, the ankle-foot orthosis group did not immediately sustain this improvement, while the foot orthosis group did. Parents preferred the foot orthosis for donning and appearance.

CONCLUSION

The ankle-foot orthosis controls idiopathic toe walking, but subjects may revert to earlier patterns following treatment. The foot orthosis does not control idiopathic toe walking as well but is less restrictive and more accepted by children and their parents, with similar out-of-brace effects.

CLINICAL RELEVANCE

This study suggests that sequential orthotic treatment for children with idiopathic toe walking (ITW) may be beneficial. Initial treatment could include a less restrictive orthosis like a foot orthosis (FO); if this is unsuccessful within a set time frame, then the patient may require a more restrictive form of treatment such as an ankle-foot orthosis (AFO).

Distal Vibration Perception Threshold in Children Who Toe Walk

PURPOSE

To compare distal vibratory perception threshold and sensation in children who toe walked (TW) and controls.

METHODS

Vibration perception threshold was measured at the metacarpal and metatarsal phalangeal (MCP and MTP) joints in 11 TW and 15 age-matched controls. Mean vibratory threshold (MVT) was calculated for each site; a Pearson correlation coefficient was determined for MVT at MCP and MTP joints. Groups were compared using a Mann-Whitney U test. Parent/caregiver responses on the Short Sensory Profile (SSP) were compared using a χ test.

RESULTS

MVTs at the MCP and MTP joints were highly correlated in both groups. MVT was higher in TW compared with controls at each site. Children who TW were more likely to have a total SSP score in the "probable difference" or "definite difference" categories compared with the "no difference" category.

CONCLUSION

Sensation should not be overlooked in the evaluation and clinical management of toe walking.

Fifteen-minute consultation: A child with toe walking

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 autism: further observations

Toe walking has been associated with language disorders and autism. To better understand the association between persistent toe walking and sensory and motor variables in children with autism, the degree of toe walking was compared with an estimate of the severity of sensory integration dysfunction symptoms and the presence of residual components of the tonic labyrinthine in supine reflex pattern in 61 children younger than 37 months of age with newly diagnosed autism. There was no association between the presence of toe walking and sensory symptoms (P = .5298) or language age (P = .6142), but there was an association between toe walking and the presence of components of the tonic labyrinthine reflex (P = .04222). These preliminary results support the contribution of subtle motor deficits to the evolution of some behaviors associated with autism.

Microswitch-aided programs to support physical exercise or adequate ambulation in persons with multiple disabilities

Three microswitch-aided programs were assessed in three single-case studies to enhance physical exercise or ambulation in participants with multiple disabilities. Study I was aimed at helping a woman who tended to have the head bending forward and the arms down to exercise a combination of appropriate head and arms movements. Study II was aimed at promoting ambulation continuity with a man who tended to have ambulation breaks. Study III was aimed at promoting ambulation with appropriate foot position in a girl who usually showed toe walking. The experimental designs of the studies consisted of a multiple probe across responses (Study I), an ABAB sequence (Study II), and an ABABB(1) sequence (Study III). The last phase of each study was followed by a post-intervention check. The microswitches monitored the target responses selected for the participants and triggered a computer system to provide preferred stimuli contingent on those responses during the intervention phases of the studies. Data showed that the programs were effective with each of the participants who learned to exercise head and arms movements, increased ambulation continuity, and acquired high levels of appropriate foot position during ambulation, respectively. The positive performance levels were retained during the post-intervention checks. The discussion focused on (a) the potential of technology-aided programs for persons with multiple disabilities and (b) the need of replication studies to extend the evidence available in the area.

Idiopathic toe-walking: have we progressed in our knowledge of the causality and treatment of this gait type?

BACKGROUND

Idiopathic toe-walking (ITW) is a condition commonly seen by podiatric physicians. Because a toe-walking gait style is also caused by or associated with many other medical conditions, podiatric physicians should pay particular attention to ensuring an accurate diagnosis. There are many reported treatment options available for ITW. Therefore, a literature review was conducted to determine what treatment options are supported by the evidence as having the best long-term effect on ITW gait.

METHODS

After extraction of relevant articles, 21 manuscripts reporting treatment options for ITW gait were appraised against the levels of evidence.

RESULTS

From these articles, there was no single treatment option reported as having a long-term effect on the gait of children with ITW. There was support in the literature for surgical interventions, serial casting, and the use of botulinum toxin type A. There was limited evidence that footwear or orthoses changed the gait pattern.

CONCLUSIONS

This review updates the knowledge of podiatric physicians, enhances how children who present with this gait style can be managed, and highlights areas for future research.

Abnormalities of joint mobility and gait in children with autism spectrum disorders

AIMS

Abnormalities of gross motor function in children with autism are well known to clinicians but have not received much empirical documentation and, with the exception of stereotypies, are not among its diagnostic criteria. We recorded the characteristics of gait and prevalence of toe walking, the range of passive joint mobility, and age at walking in children with DSM IV autism spectrum disorders (ASDs) and in age- and gender-matched typically developing peers (mean age 4years 6months, range 22months-10years 9months).

METHODS

We evaluated maximum range of mobility at the elbow, wrist, metacarpo-phalangeal, and ankle joints and videoed children walking and running. Two neurologists blind to diagnosis independently scored features of gait clinically.

RESULTS

Children with ASDs had significantly greater joint mobility (p<.002), more gait abnormalities (p<.0001), and on average walked 1.6months later than their non-autistic peers.

INTERPRETATION

This study indicates that attention should be directed to motor abnormalities as well as sociability, communication, and restricted and repetitive behaviors in individuals with ASDs. Motor deficits add to children's other handicaps. They indicate that ASDs affect a broader range of central nervous system circuitry than often appreciated.

Is idiopathic toe walking really idiopathic? The motor skills and sensory processing abilities associated with idiopathic toe walking gait

This study aimed to investigate any differences between the motor skills and sensory processing abilities of children between the ages of 4 and 8, who do and do not have an idiopathic toe walking gait. Children in each cohort were tested with a number of norm referenced assessments. A total of 60 children participated, 30 within each cohort. Those with an idiopathic toe walking gait were found to have different Sensory Profile quadrant scores (P = .002), poorer performance on the Bruininks-Oseretsky Test of Motor Proficiency (P ≤ .001), a lower vibration perception threshold (P = .001), and poorer performance on the Standing Walking Balance subtest of the Sensory Integration and Praxis Test (P = .047), compared with non-toe walking peers. Although this research does not give a causative factor for toe walking gait, it provides a number of theories as to why this gait may not be idiopathic in nature.

Botulinum toxin A does not improve the results of cast treatment for idiopathic toe-walking: a randomized controlled trial

BACKGROUND

There are many treatments for idiopathic toe-walking, including casts with or without injection of botulinum toxin A. Combined treatment with casts and botulinum toxin A has become more common even though there have been few studies of its efficacy and safety problems. Our aims were to conduct a randomized controlled trial to test the hypotheses that combined treatment with casts and botulinum toxin A is more effective than casts alone in reducing toe-walking by patients five to fifteen years of age, and that the treatment effect correlates with the extent of coexisting neuropsychiatric problems.

METHODS

All patients who had been consecutively admitted to the pediatric orthopaedics department of our institution because of idiopathic toe-walking between November 2005 and April 2010 were considered for inclusion in the study. Forty-seven children constituted the study population. The children were randomized to undergo four weeks of treatment with below-the-knee casts either as the sole intervention or to undergo the cast treatment one to two weeks after receiving injections of botulinum toxin A into the calves. Before treatment and three and twelve months after cast removal, all children underwent three-dimensional (3-D) gait analysis. The severity of the idiopathic toe-walking was classified on the basis of the gait analysis, and the parents rated the time that their child spent on his/her toes during barefoot walking. Passive hip, knee, and ankle motion as well as ankle dorsiflexor strength were measured. Before treatment, all children were evaluated with a screening questionnaire for neuropsychiatric problems.

RESULTS

No differences were found in any outcome parameter between the groups before treatment or at three or twelve months after cast removal. Several gait-analysis parameters, passive ankle motion, and ankle dorsiflexor strength were improved at both three and twelve months in both groups, even though many children still demonstrated some degree of toe-walking. The treatment outcomes were not correlated with coexisting neuropsychiatric problems.

CONCLUSION

Adding botulinum toxin-A injections prior to cast treatment for idiopathic toe-walking does not improve the outcome of cast-only treatment.

Neuropsychiatric symptoms and problems among children with idiopathic toe-walking

BACKGROUND

Idiopathic toe-walking (ITW) is a condition in which otherwise healthy children walk on their toes. The diagnosis is a diagnosis of exclusion. The aim of this study was to elucidate the occurrence of neuropsychiatric symptoms among 5- to 13-year-old children with ITW.

METHODS

Fifty-one consecutive children (31 boys, 20 girls) with a mean age of 9 years and 1 month were referred to a pediatric orthopaedic unit for ITW. Evaluations included assessments by a pediatric orthopaedic surgeon and a pediatric neurologist and the parents were asked to complete the Five to Fifteen questionnaire, a validated screening tool for neuropsychiatric problems. The study cohort was compared with an age-matched normative group previously described.

RESULTS

In the study group, the percentage of children scoring above the 90th percentile, indicating difficulties, were for the different domains; motor skills 39.0%, executive functions 17.6%, perception 25.5%, memory 23.5%, language 23.5%, learning 25.9%, social skills 25.5%, and emotional/behavioural problems 21.6%.

CONCLUSIONS

Children with ITW as a group displayed more neuropsychiatric problems than a normative group of age-matched children. These findings merit future larger studies. Furthermore, when children with ITW are referred for orthopaedic or neurological assessment, a structured neuropsychiatric history is advisable and further neuropsychiatric investigations should be considered.

LEVEL OF EVIDENCE

II.

Age at diagnosis of autism spectrum disorders

Early identification of autism has become a national priority but, despite efforts, there are children who are being identified at a later age. In this study, children of Hispanic and African American origin, foreign-born children, and children born to foreign mothers were more likely to be diagnosed later.

The prevalence and course of idiopathic toe-walking in 5-year-old children

BACKGROUND

Children walking on their toes instead of with a typical gait, without evidence of an underlying medical condition, are defined as idiopathic toe-walkers. The prevalence of idiopathic toe-walking is unknown.

METHODS

A cross-sectional prevalence study of 5.5-year-old children (n = 1436) living in Blekinge County, Sweden, was performed at the regular 5.5-year visit to the local child welfare center. Children were assessed for a history of toe-walking or whether they still walked on their toes. Additionally, all 5.5-year-old children (n = 35) admitted to the clinic for children with special needs in the county were assessed.

RESULTS

Of the 1436 children in the cohort (750 boys, 686 girls), 30 children (2.1%, 20 boys and 10 girls) still walked on their toes at age 5.5 years and were considered as active toe-walkers. Forty children (2.8%, 22 boys and 18 girls) had previously walked on their toes but had stopped before the 5.5-year visit and were considered as inactive toe-walkers. At age 5.5 years, the total prevalence of toe-walking was 70 (4.9%) of 1436. For children with a neuropsychiatric diagnosis or developmental delay, the total prevalence for active or inactive toe-walking was 7 (41.2%) of 17.

CONCLUSIONS

This study establishes the prevalence and- early spontaneous course of idiopathic toe-walking in 5.5-year-old children. At this age, more than half of the children have spontaneously ceased to walk on their toes. The study confirms earlier findings that toe-walking has a high prevalence among children with a cognitive disorder.

Automated method to distinguish toe walking strides from normal strides in the gait of idiopathic toe walking children from heel accelerometry data

Toe walking mainly occurs in children due to medical condition or physical injury. When there are no obvious signs of any medical condition or physical injury, a diagnosis of Idiopathic Toe Walking (ITW) is made. ITW children habitually walk on their toes, however can modify their gait and walk with a heel-toe gait if they want to. Correct gait assessment in ITW children therefore becomes difficult. To solve this problem, we have developed an automated way to assess the gait in ITW children using a dual axis accelerometer. Heel acceleration data was recorded from the gait of ITW children using boots embedded with the sensor in the heel and interfaced to a handheld oscilloscope. An innovative signal processing algorithm was developed in IgorPro to distinguish toe walking stride from normal stride using the acceleration data. The algorithm had an accuracy of 98.5%. Based on the statistical analysis of the heel accelerometer data, it can be concluded that the foot angle during mid stance in ITW children tested, varied from 36° to 11.5° while as in normal children the foot stance angle is approximately zero. This algorithm was later implemented in a system (embedded in the heel) which was used remotely to differentiate toe walking stride from normal stride. Although the algorithm classifies toe walking stride from normal stride in ITW children, it can be generalized for other applications such as toe walking in Cerebral Palsy or Acquired Brain Injury subjects. The system can also be used to assess the gait for other applications such as Parkinson's disease by modifying the algorithm.

Persistent toe walking in autism

The records of 954 ambulatory children presenting for initial evaluation to a university developmental pediatrician were reviewed for the prevalence of persistent toe walking and associated tight heel cords. The incidence of persistent toe walking (20.1%) and tight heel cords (12.0%) were found to be higher in 324 children with an autistic spectrum disorder but lower (10.0%/3.0%) in 30 children with Asperger syndrome. These results confirm the previously reported high incidence of toe walking in children with autism and with language disorders and also raise the possibility of a secondary orthopedic deformity that can complicate long-term management of these patients.

Idiopathic toe-walking in children, adolescents and young adults: a matter of local or generalised stiffness?

Background

Idiopathic Toe Walking (ITW) is present in children older than 3 years of age still walking on their toes without signs of neurological, orthopaedic or psychiatric diseases. ITW has been estimated to occur in 7% to 24% of the childhood population. To study associations between Idiopathic Toe Walking (ITW) and decrease in range of joint motion of the ankle joint. To study associations between ITW (with stiff ankles) and stiffness in other joints, muscle strength and bone density.

Methods

In a cross-sectional study, 362 healthy children, adolescents and young adults (mean age (sd): 14.2 (3.9) years) participated. Range of joint motion (ROM), muscle strength, anthropometrics sport activities and bone density were measured.

Results

A prevalence of 12% of ITW was found. Nine percent had ITW and severely restricted ROM of the ankle joint. Children with ITW had three times higher chance of severe ROM restriction of the ankle joint. Participants with ITW and stiff ankle joints had a decreased ROM in other joints, whereas bone density and muscle strength were comparable.

Conclusion

ITW and a decrease in ankle joint ROM might be due to local stiffness. Differential etiological diagnosis should be considered.

Idiopathic toe walking and sensory processing dysfunction

BACKGROUND

It is generally understood that toe walking involves the absence or limitation of heel strike in the contact phase of the gait cycle. Toe walking has been identified as a symptom of disease processes, trauma and/or neurogenic influences. When there is no obvious cause of the gait pattern, a diagnosis of idiopathic toe walking (ITW) is made. Although there has been limited research into the pathophysiology of ITW, there has been an increasing number of contemporary texts and practitioner debates proposing that this gait pattern is linked to a sensory processing dysfunction (SPD). The purpose of this paper is to examine the literature and provide a summary of what is known about the relationship between toe walking and SPD.

METHOD

Forty-nine articles were reviewed, predominantly sourced from peer reviewed journals. Five contemporary texts were also reviewed. The literature styles consisted of author opinion pieces, letters to the editor, clinical trials, case studies, classification studies, poster/conference abstracts and narrative literature reviews. Literature was assessed and graded according to level of evidence.

RESULTS

Only one small prospective, descriptive study without control has been conducted in relation to idiopathic toe walking and sensory processing. A cross-sectional study into the prevalence of idiopathic toe walking proposed sensory processing as being a reason for the difference. A proposed link between ITW and sensory processing was found within four contemporary texts and one conference abstract.

CONCLUSION

Based on the limited conclusive evidence available, the relationship between ITW and sensory processing has not been confirmed. Given the limited number and types of studies together with the growing body of anecdotal evidence it is proposed that further investigation of this relationship would be advantageous.

Effects of motor control intervention for children with idiopathic toe walking: a 5-case series

PURPOSE

To describe and evaluate the effects of motor control intervention in young children diagnosed with idiopathic toe walking.

METHODS

Five children received motor control intervention in a multiple-case series design using a nonconcurrent, variable baseline. Multiple gait measures were taken before and during the intervention phase. Pre- and posttreatment measures of gross motor development and ankle dorsiflexion range of motion were compared.

RESULTS

During the intervention phase, heel strike frequency showed an upward slope for 1 participant, slight upward trends for 3 participants, and no change for 1 participant. Parents indicated minimal gait change within the children's regular environments. Gross motor skill scores increased but were not statistically significant. Passive ankle range of motion improved and was maintained (P = .002).

CONCLUSIONS

Presentation of children with idiopathic toe walking varies and refinement is needed for gait measures and assessment methods. Intervention improved ankle mobility, but additional components appear necessary to attain spontaneous heel-toe gait.

Relation Between Cognitive and Motor Performance in 5- to 6-Year-Old Children: Results From a Large-Scale Cross-Sectional Study

The relation between cognitive and motor performance was studied in a sample of 378 children aged 5-6. Half of these children had no behavior problems; the others were selected for externalizing (38%) or internalizing problems (12%). Quantitative and qualitative aspects of motor performance were related to several aspects of cognition, after controlling for the influence of attention. No relation between global aspects of cognitive and motor performance was found. Specific positive relations were found between both aspects of motor performance, visual motor integration and working memory, and between quantitative aspects of motor performance and fluency. These findings reveal interesting parallels between normal cognitive and motor development in 5- to 6-year-old children that cannot be ascribed to attention processes.