habitual toe objectives walking - podiatry m · solely as habitual toe walkers exhibit a slight...

Learn to evaluate and treat this idiopathicchildhood condition.

Habitual ToeWalking

Learn to evaluate and treat this idiopathicchildhood condition.

Habitual ToeWalking

ObjectivesAfter reading this article the pod-iatric physician should be able to:

1) Recognize a pediatric patientthat exhibits habitual toe walking

2) Take a proper medical andfamily history of a child suspectedof toe walking

3) Understand other medicalconditions that may cause a childto toe walk

4) Perform an appropriate phys-ical examination to rule out nonidiopathic toe walking etiologies

5) Develop a treatment plan fora child that is determined to be ahabitual (idiopathic) toe walker

NOVEMBER/DECEMBER 2002 • PODIATRY MANAGEMENTwww.podiatrym.com 163

idiopathic toe walking. The usualdevelopmental sequence for learn-ing to walk does not include walk-ing on the toes29 and generally pro-ceeds gradually to a heel-toe patternwith a heel strike at 18 months anda heel-to-toe gait achieved by agethree.37 Tiptoe walking, though, isconsidered by many to be a normalvariant or phase that some children

go through when learning towalk,8,16,17,40 which is generally out-grown three to six months after firstwalking34,40 or by age seven.20 Yet toewalking has been observed well intoadolescence and even adulthood.

The etiology of toe walking hasbeen attributed to: congenital shorttendo calcaneus;17 abnormal soleus

Continued on page 164

Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Continu-ing Medical Education by the Council on Podiatric Medical Education.

You may enroll: 1) on a per issue basis (at $15 per topic) or 2) per year, for the special introductory rate of $99 (you save $51).You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the near future, you maybe able to submit via the Internet.

If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned credits. You willalso receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. Alist of states currently honoring CPME approved credits is listed on pg. 176. Other than those entities currently accepting CPME-approvedcredit, Podiatry Management cannot guarantee that these CME credits will be acceptable by any state licensing agency, hospital, man-aged care organization or other entity. PM will, however, use its best efforts to ensure the widest acceptance of this program possible.

This instructional CME program is designed to supplement, NOT replace, existing CME seminars. Thegoal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts bynoted authors and researchers. If you have any questions or comments about this program, you can write or call us at: PodiatryManagement, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected].

Following this article, an answer sheet and full set of instructions are provided (p. 176).—Editor

Habitual toe walking is a con-dition in which orthopedical-ly and neurologically normal

children prefer to and persistentlyambulate on the balls of their feet.Since this type of gait pattern inchildren is not truly a habit, betterterms may include idiosyncratic or

By Mark A. Caselli, DPM

Continuing

Medical Education

C L I N I C A L P O D I A T R YC L I N I C A L P O D I A T R Y

ed to occur in 7% to 24% of the nor-mal childhood population.1,8,15

Medical and Family HistoryThe diagnosis of habitual toe

walking is one of exclusion, inwhich other causes of toe walking,such as ankle equinus, cerebralpalsy, or myopathy are ruledout.16,20,26 A thorough medical histo-

ry, family history, gait evaluation,musculoskeletal examination, andneurologic examination are neces-sary for this purpose.

A prenatal, intrapartum, andpostnatal history is of paramountimportance in ruling out neuromo-tor disease. The prenatal historyshould include family as well as ma-ternal history. It is important to as-certain whether or not other mem-

bers of the family are toe walkers.Family history of toe walking in theliterature ranges from 10% to 88%and is considered to be a character-istic of toe walking (Table 1). Preg-nant women at both extremes ofthe reproductive age group, under16 and over 30, are in the obstetrichigh-risk group, which may lead toneurologic deficit in the newborn.Previous obstetric history, includingnumber of pregnancies, miscar-riages, birth weight, and health sta-tus of other children, should be ob-tained. A history of having takenany medicines or home remediesduring pregnancy as well as drugabuse, both narcotic and non-nar-cotic, is important since they mayaffect the fetus and the newborn.Length of gestation should be ob-tained since premature and postma-ture infants are at risk. The mother’sown measure of fetal activity issometimes helpful in assessing ma-turity and vigor of the fetus.

Intrapartum events, such as fetalheart rate, rupture of membranes,length of labor, maternal medica-tions, and other complications oflabor and delivery should be ob-tained. The history of the immediatepostnatal course, including fetal dis-tress and hypoxic episodes, can indi-

muscle;40 unknown central nervoussystem defect;20 autosomal dominantinheritance with unequal peni-trance;24 delayed maturation of thecortical spinal tract;40 normal transientphase of development;42 vestibulardysfunction;12,25 viruses;7 time spent inbaby walkers;5 and habit.16 Thoughthe actual cause of idiopathic toewalking is unknown, muscle biopsiestaken from a group of 25 toe walkersdemonstrated some common abnor-malities in the muscle fibers and asso-ciated capillaries suggesting that theremight be an underlying neuropathicprocess.14 Toe walking has also beenfound to occur with high frequencyin children with cerebral palsy4 andmuscular dystrophy31 and has been as-sociated with autism,42 childhoodschizophrenia,12 delayed language de-velopment,1,2 and low IQ.2

Studies in the literature that dealwith toe walking that is not associat-ed with neuromuscular or mentaldisease vary in their conclusionsfrom toe walking having no long-term neuro-orthopedic consequencesto the possibility that persistent toewalking results in significant ankleequines, requiring surgery (Table 1).Toe walking that is not associatedwith cerebral palsy has been estimat-

Toe Walking...Con

tinuin

g

Medica

l Edu

catio

n


164 www.podiatrym.comPODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2002

TABLE 1TOE WALKING STUDIES

Study Number Family History (%) First Walked (Months) Ankle Dorsiflexion

Sobel and Caselli33 60, ages 1-15 years 30 11.1 -20˚ to +40˚(33 males, 27 females) (Average +6.2˚)

Hall et al17 20 10 — -30˚ to -60˚(15 males, 5 females)

Griffin et al16 6, ages 5-9 years 67 8-13 -10˚ to +5˚(3 males, 3 females)

Furrer15 28 50 13 +4˚ to +16˚(20 males, 8 females)

Katz and Mubarak21 8 88 — -10˚ to +5˚(4 males, 4 females) (Average 0˚)

Kalen et al20 18 71 11.7 -30˚ to +5˚(14 males, 4 females) (Average -10˚)

Hicks et al18 7 — 12.3 -5˚ to +20˚(Average 3˚)

A normal child will tend to become

fatigued while walkingon his/her toes much

earlier than the habitual toe walker.

between 9 and 15 months. Toewalkers have been reported to walkon time, begin toe walking immedi-ately when first starting to walk andare usually able to demonstrate aheel-toe gait (Table 1). A child withhabitual toe walking will usuallyhave a normal birth and develop-mental history. The length of timethe child remains on his toes com-pared to the total length of ambula-tion time and whether or not this

ratio is increasing or decreasing isimportant in predicting the courseof the toe walking.

Gait EvaluationThe initial approach to the child

with habitual toe walking shouldconsist of gait analysis, beginningwith careful gait observations. Thechild should be evaluated with andwithout shoe gear, since shoes canoften mask the true nature of thechild’s gait pattern. The followingare observations that are consistentwith the diagnosis of habitual toewalking. These observations aremade with the child walking bare-foot.(Fig. 1)

1) The child walks on his/hertoes (balls of their feet) in a well co-ordinated, balanced, and efficientmanner.

2) While toe walking, the child ex-hibits a normal angle and base of gait.

3) The child is capable of run-ning with minimal to no tripping orfalling.

4) The child is capable of walk-ing both forward and backward easi-ly while toe walking.

5) The child is capable of stand-ing with his/her heels on theground (full foot contact).

6) The child may take his/herfirst few steps in a heel-to-toe orfull-foot contact fashion and rise totoe walking only when increasingthe speed of ambulation.

In summary, the gait observa-tions of a child with habitual toewalking should be similar to thoseof a normal well-coordinated childwho has elected to walk on his/hertoes for a short period of time, theone distinguishing difference beingthat the normal child will tend tobecome fatigued while walking onhis or her toes much earlier than thehabitual toe walker.

There are several gait analysis tech-niques, including the tread mat andvideo recording, that can be valuabletools in both the diagnosis and assess-ment of the progression of habitualtoe walking. These methods also pro-vide a permanent, objective record.

Tread MatThe tread mat (as modified from

the original clinical descriptions andapplications of Richard O. Schuster,

cate injury to the central nervoussystem. Birth weight and length ofhospital stay is important and easily-obtained historical information.

The next part of the historyshould consist of obtaining thechild’s developmental milestones. Achild should be able to sit uprightindependently by six to sevenmonths and should begin walking

Toe Walking...Con

tinuin

g

Medica

l Edu

catio

n



Fig. 3: Scissor gait of spastic cerebralpalsy.

Fig. 4: Pseudoscissor gait can mimiccerebral palsy.

Fig. 1: Typical stance of a habitual (id-iopathic) toe walker.

Fig. 2: A tread mat is a simple toolthat can demonstrate valuable gaitpattern information.

Physical ExaminationA thorough musculoskeletal ex-

amination should be performed onall patients presenting with a chiefcomplaint of habitual toe walking.The static lower extremity examina-tion of the habitual toe walkershould demonstrate normal foot andleg alignment and appearance. Thereshould be no significant frontal,transverse, or sagittal plane deformi-ties and no signs of muscle atrophy.Special attention must be paid to theevaluation of ankle dorsiflexion. Thehabitual toe walker will usuallydemonstrate at least 5 to 10 degreesof passive ankle dorsiflexion with theknee extended and the subtalar jointheld in its neutral position.(Table 1)Although some patients diagnosedsolely as habitual toe walkers exhibita slight ankle equinus, this appearsto be an accommodation secondaryto them spending long periods oftime toe walking.33 A significantankle equinus, even if present, doesnot appear to be the prime etiologyof habitual toe walking.

Habitual toe walkers shoulddemonstrate a normal neurologic sta-tus. In addition to exhibiting normalneuromotor development for theirage, their deep tendon reflexes, vibra-tory, positional, pain, and tempera-ture sensations as well as their mus-cle power should be within normallimits. Electromyographic studies ofGriffin et al16 showed that habitualtoe walkers demonstrated no evi-dence of clonus or of muscle activityat rest. These studies further showedthat gastrocnemius and soleus-mus-cle activity during the swing phasewas present during toe-toe gait inboth normal walkers as well as in ha-bitual toe walkers. Before treatment,habitual toe walkers demonstratedincreased amplitude and prolongedduration of activity of the tibialis an-terior muscle during heel-toe gait aswell as overlap of tibialis anterior ac-tivity with gastrocnemius and soleusactivity. After treatment with serialcasts, the gait pattern of the habitualtoe walkers as recorded electromyo-graphically was normal.

Differential DiagnosisHabitual toe walking is a diagno-

sis of exclusion and therefore earlyexamination of toe walkers is impor-

asking the parent to stand at the op-posite end of the paper. As the childwalks or runs to the parent, a pow-der impression is made on the paper.

In evaluating a child with habit-ual toe walking the percentage offorefoot and heel contact can be as-sessed by observing the transferenceof powder onto the paper. This tech-nique will often reveal signs of heelcontact that may not be discernibleby visual gait analysis. The treadmat can also be used to evaluate theangle of gait, base of gait, length ofstep, and width of stride.

Video Gait AnalysisVideo gait analysis is a useful tool

in the evaluation of habitual toewalking as well as any other gait dis-

turbance. Video gaitanalysis allows for bothslow motion and stopframe evaluation of gaitpatterns. Straight-linecomparison drawings canbe made; thus, measure-ments such as heel eleva-tion at any given phaseof gait can be comparedfrom one visit to thenext. This analysis pro-vides an invaluable toolin maintaining accuraterecords of progress overthe treatment period.

DPM) is a simple, inexpensivemethod of creating a permanentrecord of a child’s gait pattern. (Fig.2) It reveals changes that are not al-ways perceptible to the eye. The ma-terials required for making a treadmat include (1) a roll of dark coloredpaper, approximately 20 incheswide; (2) fine powder such a talc orplaster powder; and (3) a can of hairspray to permanently affix the pow-der to the paper, if so desired. Theprocedure for making a tread mat in-cludes placing the powder at the endof a 15 to 25 foot strip of paper. Thechild is then placed in the powderand encouraged to walk along themat. This can be accomplished by

Toe Walking...Con

tinuin

g

Medica

l Edu

catio

n



Fig. 5: Classic high top straight last shoe is effectivein inhibiting toe walking progression.

hibits no signs of spasticity orneuromotor deficit.

Mental RetardationMental retardation is often associat-

ed with toe walking.22,25 Mental retarda-tion refers to cognitive ability (as mea-sured by intelligence tests) and to theresultant summation of a person’s com-petency in social adaptation. It is often

Continuing

Medical Education

curs when there exists a combina-tion of habitual toe walking and ad-ducted limb position due to internaltibial torsion and/or internal femoralposition (femoral antetorsion). Thechild with a pseudoscissor gait pat-tern usually demonstrates greaterstability than the child with a scissorgait from cerebral palsy. Althoughthe child with a pseudoscissor gaitmay frequently trip and fall, he ex-

Toe Walking...

tant in differentiating the habitualtoe walker from the following seri-ous neuromuscular, psychological,and skeletal pathologies that cancause other forms of toe walking.

Cerebral PalsyCerebral palsy (perinatal en-

cephalopathy)3,10,27,30,38 is a fixed non-progressive neurologic deficit ac-quired before, during, or in themonths after birth. Despite the non-progressive nature of the damage, theclinical expression may change asthe child matures. The medical histo-ry may reveal perinatal cerebral in-jury. Although there are many formsof cerebral palsy, the most commonand the one most likely to produce atoe walking-like gait is the spasticform.30 Neuromotor developmentalmilestones, including independentambulation, are usually significantlydelayed. The physical examinationdemonstrates increased tone, hyper-active reflexes, and an extensor plan-tar response. The child is usuallybrought to the physician out of fearof motor retardation. A movementdisorder may occur in any singlelimb or any combination of limbs.

Talipes equinovarus or equino-valgus foot deformities are oftenpresent along with an unstable scis-sor gait pattern.(Fig. 3) The equinuscan be due to a spastic gastrocne-mius or gastrocnemius and soleusmuscle. Electromyographic studies30

have demonstrated that some cere-bral palsy patients have a primitiveextensor reflex elicited by knee ex-tension that causes contraction ofboth the soleus and gastrocnemiusmuscle. Presence of the primitiveextensor reflex or spasticity of thegastrocnemius muscle correspondsto a bouncing gait pattern in whichthe heel comes down when the kneeis bent. Studies have suggested thatelectromyographic testing may behelpful in differentiating patientswith mild cerebral palsy from thosewith idiopathic toe walking.28,33,38

Pseudoscissor GaitA variant of habitual toe walking,

pseudoscissor gait, must be recog-nized and differentiated from thescissor gait pattern of cerebralpalsy.(Fig. 4) Pseudoscissor gait oc-



AutismAutistic11,12,22,41,42 children are prin-

cipally disturbed in their lack ofemotional rapport and in their be-havioral characteristics. They showseclusiveness, irritability whenseclusiveness is disturbed, daydreaming, bizarre behavior, decreaseof interest, regression of interper-sonal interests, and sensitivity tocriticism. There is a gradual with-drawal from affective contact withpeople and an increasing tendencyto brood. Speech becomes disorga-nized and limited to early infantileinterest. Among 52 3-13 year-oldautistic children, Colbert and Koe-gler found ten persistently toewalked.11 This toe walking was notan isolated phenomenon, but onlypart of their spontaneous whirling,dancing, and jumping behavior.12,22

All of these children tested as beingmentally defective but their neuro-logic examinations were within nor-mal limits. Weber42 notes that thedefinitive stepping movements priorto autonomous walking by a normalchild take place on the forefoot be-tween the 9th and 16th months.She concluded that toe walking byboth autistic and nonautistic chil-dren with developmental distur-bances (but without pyramidalsymptoms) arises from the “fixationof a normal transient stage of devel-opment.”

DiastematomyeliaDiastematomyelia19,41 consists of

a partial or complete division of thespinal cord by tissue located in themidline of the spinal canal. Neuro-logic deficits are usually not appar-ent at birth. The spinal cord is teth-ered to the spinal canal, whichgrows caudally relative to the cord.A mixed upper and lower motorneuron deficit involving bladderand bowel function and progressivedisturbances in gait begin to devel-op at two or three years of age. Sus-picion is aroused by overlapping cu-taneous anomalies such as hypertri-choses, dimples, lipomas, or vascu-lar malformations. A cavus deformi-ty of the feet is common. The feettake on varus or valgus positionsdue to flaccid or spastic paralysis.Foot ulcerations appear due to anal-gesia and trauma. Differentiation

to others such as rocking, head bang-ing, and temper tantrums are likely.

Neurologic functioning is fre-quently altered as evidenced by hy-pertonicity, hypotonicity, ataxia, al-tered reflexes, poor coordination,and seizures. Speech is delayed andfacial expression often shows the“stigmata of degeneracy.”32,41

Toe walking among mentally re-tarded children is seen byMontgomery25 as beingdue to vestibular dys-function. Immediatelyafter vestibular stimula-tion (trampoline bounc-ing and spinning in ahammock), 13 of 17mentally retarded toewalkers temporarily dis-continued toe walking.Montgomery found thatthe most consistent find-ing among the 17 men-tally retarded childrenwho toe walked was hy-potonia and inadequatevestibular integration.

possible to imply mental deficiency ininfancy by recognizing the infants’total disorder (for example, Down syn-drome). Behavioral clues to the diagno-sis include perseveration, dependencyon routine, distractibility, fear, lack ofspontaneity, and poor judgment.Repetitive physical activities disturbing

Toe Walking...Con

tinuin

g

Medica

l Edu

catio

n



Fig. 6: Construction type boots with outer sole wedgeoffer a more acceptable approach for many parents.

equines, can be usefully applied to evaluate non-spastic short calf muscles.27,35,38 Limited dorsiflexionpresent with the knee extended and absent with theknee flexed indicates a functionally shorter gastrocne-mius muscle. Dorsiflexion limited equally with knee ex-tended or flexed is consistent with a combined gastroc-

nemius soleus muscle equinus.Clinically, a child with a gastroc-

nemius soleus muscle equinus willstand with an abducted stance angleand will often exhibit a genu recurva-tum (knee hyperextension) and signif-icant midtarsal pronation. The childwalks and runs with an early heel lift-off creating a bouncing gait pattern.

TreatmentAlthough habitual toe walking is

often considered a transient retarda-tion of a normal stage of development,

it is nevertheless associated with problems that warrantactive treatment. Ambulation is awkward and whencombined with internal limb rotational deformities willoften lead to instability with injuries due to trippingand falling. Decreasing the toe walking attitude and ac-celerating the progression to heel-toe gait is also valu-able in decreasing parents’ anxiety over this condition

Continuing

Medical Educationfrom habitual toe walking is made easier by the pro-gressive nature of diastematomyelia where toe walkingbegins at two or three years of age and increases inseverity. Habitual toe walking is present at the start ofautonomous walking and diminisheswith age.

Muscular DystrophyMuscular dystrophy39 of the

Duchenne as well as the mild limb-gir-dle form are associated with toe walk-ing. The toe walking and a pointedfoot posture at rest are the result of adisturbance of the antagonistic bal-ances of the variously afflicted musclegroups. Contractures appear aftersome years. If the diagnosis of muscu-lar dystrophy is missed and patient isimmobilized either to stretch the triceps surae or postsurgical lengthening, it is very difficult to recover mus-cle function. Temporal clues are important in ruling outmuscular dystrophy as a cause of toe walking in a child.Limb girdle muscular dystrophy’s first symptoms usuallyappear in the second decade. With the more commonDuchenne muscular dystrophy, the child may walk laterthan expected with frequent falls while learning towalk. The toe walking is not evident until three or fouryears of age and progressively increases. Other signs ofDuchenne muscular dystrophy include rocking fromside to side with a waddling gait, lumbar lordosis, anddifficulty in climbing stairs and rising from the floor.

Gastrocnemius Soleus Muscle EquinusGastrocnemius soleus muscle equinus is probably the

most common entity to be ruled out in considering thediagnosis of habitual toe walking.3 Indeed, the authorhas found that many persistent habitual toe walkersdemonstrated a slight limitation of ankle dorsiflexion,but hardly enough to be responsible for the observed 30to 60 degrees of positional equinus during gait.

The Silfverskjold test, first used to differentiate spas-tic gastrocnemius equinus from spastic gastrocsoleus

Toe Walking...



Treatment of habitual toe walkers

might include shoe therapy, orthosis

therapy, auditoryfeedback, and surgery.

Fig. 7: Gait plates may help in mild cases of toe walkingwith intoe gait.

heel from slipping out the back ofthe shoe and also allows for the inte-rior modification of the shoe such asthe addition of heel lifts. The effec-tiveness of the shoes in inhibitingtoe walking can be enhanced byadding a 1/8 to 3/8 inch outer solewedge. The wedge increases therigidity of the sole as well as induc-ing foot abduction that furtherforces the heels to the ground. Inolder children, we have found itbeneficial to increase the height ofthe heel of the shoe to the point atwhich the child exhibits a heel-toegait pattern. The heel height is laterreduced gradually on subsequent vis-its every few months. A high topconstruction boot with a rigid soleand outer sole wedge can also beused. (Fig. 6) The author has foundthis treatment modality to be veryeffective in reducing the toe walkingprogression. The key to success inshoe therapy is to start treatment ata young age (as soon as toe walkingis noticed) and continue use of theshoes until the child no longer toewalks when barefoot. The rigid shoesare often worn for six months to twoyears (the older the child, the longerthe shoes are worn).

Orthosis TherapyOrthotic devices used in the treat-

ment of habitual toe walking includeheel lifts, gait plates and ankle-footorthoses. Heel lifts placed in shoes ac-commodate for the dynamic equinusand act as a biofeedback for musclecognition by providing propriocep-tion to the heels during gait. The liftsshould be high enough to make con-tact with the heels during gait andthen gradually reduced. Gait plates,

rigid foot orthoses designed to induceout-toe, may be of benefit in mildcases of habitual toe walking. (Fig.7)The gait plate orthoses are used inflexible soled sneakers and the resul-tant abductory influence will oftenbring the heels down to the ground.Ankle-foot orthoses, braces that pre-vent motion from occurring at theankle, can be used as both ambulato-ry devices and as night splints. (Fig.8) During ambulation, these devicesserve as a viable alternative to walk-ing casts and as night splints theymay be used to prevent the develop-ment of contractures in the posteriorleg musculature.

Short leg walking casts6,16,26 appliedfrom six to eight weeks have beenshown to be successful in the treat-ment of habitual toe walkers. (Fig. 9a& 9b) Electromyographic studies per-formed after this regimen of treat-ment revealed a normal gait pattern.

Auditory FeedbackAuditory feedback, as a method of

cognitive muscle management, hasbeen shown to have a positive effecton reducing toe walking. In onestudy,13 eight children with dynamicequinus were able to increase thetime their heels contacted the groundby 45 percent and the number oftimes their heels contacted theground by 42 percent six monthsafter the end of augmented auditoryfeedback training. Seven of the eightoriginally could have their anklesdorsiflexed to the perpendicular andone child lacked five degrees to reachthe perpendicular with his foot in-verted and knee in extension. Aswitch had been placed under themore involved heel and bringing the

heel down produceda sound. Each childsought to achievethat sound as fre-quently and for aslong as possible dur-ing three months ofone hour daily prac-tice sessions.

SurgicalIntervention

Surgical length-ening of the Achillestendon should onlybe considered when

as well as probably reducing astructural ankle equinus that may re-sult from persistent toe walking.33

Many approaches have been em-ployed in the treatment of the childwith habitual toe walking. Thesemethods include shoe therapy, or-thoses, serial casting, cognitive mus-cle management, and surgery.

Shoe TherapyShoe therapy consists of the use

of a rigid sole straight last shoe. Therigid sole does not permit the childto dorsiflex at his metatarsal-pha-langeal joint, preventing forefootsupport and thus bringing the heeldown to the ground. Whenever pos-sible, high top shoes should beused.(Fig. 5) This prevents the child’s

Toe Walking...Con

tinuin

g

Medica

l Edu

catio

n


Fig. 9: a & b Walking casts can be fabricated from (a) plaster or (b) fiberglass.

Fig. 8: An ankle foot orthosis (AFO)prevents toe walking progression.


26 Papariello SG, Skinner SR: Dynamicelectromyography analysis of habitual toe-walkers. J Pediatr Orthop 5: 171, 1985.

27 Perry J, Hoffer MM, et al: Gait analysisof the triceps surae in cerebral palsy. J BoneJoint Surg 56A: 511-520, 1974.

28 Policy JF, Torburn L, Rinsky LA, et al:Electromyographic test to differentiate milddiplegic cerebral palsy and idiopathic toe-walking. J Pediatr Orthop Nov-Dec; 21(6):784, 2001.

29 Rang M: “Toeing In and Toeing OutGait Disorders,” in The Art and Practice of Pe-diatric Orthopedics, 1st Ed., ed by D Wenger,M Rang, Raven Press, New York, 1993.

30 Sharrard WJW, Bernstein S: Equinusdeformity in cerebral palsy. J Bone Joint Surg54B: 272-276, 1972.

31 Shield LK: Toe walking and neuromus-cular disease. Arch Dis Child 59: 1003, 1984.

32 Smith DW: Introduction to ClinicalPediatrics (second edition). Philadelphia,W.B. Saunders, 1977.

33 Sobel E, Caselli MA, Velez Z: Effects ofpersistent toe walking on ankle equinus:analysis of 60 idiopathic toe walkers. JAPMA87: 17, 1997.

34 Statham L, Murray MP: Early walkingpatterns of normal children. Clin Orthop 79:8, 1971.

35 Strayer LM: Gastrocnemius recession. JBone Joint Surg 40A: 1019-1030, 1958.

36 Stricker SJ, Angulo JC: Idiopathic toewalking: a comparison of treatment meth-ods. J Pediatr Ortho May-Jun; 18(3): 289,1998.

37 Sutherland DH, Olshen R, Cooper L, etal: The development of mature gait. J BoneJoint Surg (Am) 62: 336, 1980.

38 Sutherland DH: Gait analysis in cere-bral palsy. Develop Med Child Neurol20:807-813, 1978.

39 Swaiman KF, Wright FS: Pediatric Neu-romuscular Diseases. St. Louis, Mosby, 1979.

40 Tachdjian MO: “The Foot and theLeg,” in Pediatric Orthopedics, Vol 2, WBSaunders, Philadelphia, 1972.

41 Tax HR: Podopediatrics (second edi-tion). Baltimore, Williams and Wilkins, 1985.

42 Weber D: “Toe-walking” in childrenwith early childhood autism. Acta Paedopsy-chiatr 43: 73, 1978.

its management. Foot Ankle 4: 149, 1983.5 Blocky NJ: “Minor Problems,” in Chil-

dren’s Orthopaedics—Practical Problems,Butterworth’s, London, 1976.

6 Brouwer B, Davidson LK, Olney SJ: Seri-al casting in idiopathic toe-walkers and chil-dren with spastic cerebral palsy. J PediatrOrtho Mar-Apr; 20(2): 221, 2000.

7 Buie WWB: Acute toe walking syn-drome. Med J Aust 2: 752, 1975.

8 Burnet CN, Johnson EW: Developmentof gait in childhood: part I. Dev Med ChildNeurol 13: 207, 1971.

9 Caselli MA, Rzonca EC, Lue BY: Habitu-al toe-walking: evaluation and approach totreatment. Clin Podiatr Med Surg 5: 547,1988.

10 Chong KC, Vojnic CD, et al: The as-sessment of the internal rotation gait in cere-bral palsy. Clin Ortho Related Res 132:145-150, 1978.

11 Colbert EG, Koegler RR, et al: Vestibu-lar dysfunction in childhood schizophrenia.Arch Gen Psych 1:62-79, 1959.

12 Colbert EG, Koegler RR: Toe walking inchildhood schizophrenia. J Pediatr 53: 219,1958.

13 Conrad L, Bleck EE: Augmented audi-tory feedback in the treatment of equinusgait in children. Develop Med Child Neurol22: 713-718,1980.

14 Eastwood DM, Dennett X, Shield LK,et al: Muscle abnormalities in idiopathic toe-walkers. J Pediatr Orthop Jul; 6(3): 215, 1997

15 Furrer FD: Persistent toe-walking inchildren. Helv pediatr Act 37: 301, 1982.

16 Griffin PP, Wheelhouse WW, Shiavi R,et al: Habitual toe walkers: a clinical and elec-tromyographic gait analysis. J Bone JointSurg 59A: 97, 1977.

17 Hall JE, Salter RB, Bhalla SK: Congeni-tal short tendo calcaneus. J Bone Joint Surg49B: 695, 1967.

18 Hicks R, Durinick N, Gage JR: Differen-tiation of idiopathic toe-walking and cerebralpalsy. J Pediatr Orthop 8: 160, 1988.

19 Jabbour JT, Duenas DA, et al: PediatricNeurology Handbook (second edition).Flushing, Medical Examination, 1976.

20 Kalen V, Adler N, Bleck EE: Elec-tromyography of idiopathic toe walking. JPeatr Orthop 6: 31, 1986.

21 Katz MKM, Mubarak S: Hereditarytendo Achilles contractures. J Pediatr Orthop4: 711, 1984.

22 Kinnealey M: Aversive and nonaver-sive responses to sensory stimulation in men-tally retarded children. Am J Occup Ther27:464-467, 1973.

23 Kogan M, Smith J: Simplified approachto idiopathic toe-walking. J Pediatr OrthoNov-Dec; 21(6): 790, 2001.

24 Levine MS: Congenital short tendo cal-caneus: report of a family. Am J Dis Child125: 858, 1973.

25 Montgomery P, Gauger J: Sensory dys-function in children who toe walk. Phys Ther58: 1195, 1978.

a significant structural gastrocsoleusmuscle equinus can be demonstrated.It must be emphasized that the struc-tural equinus probably represents aconcomitant physical finding and isnot the primary etiology of the toewalking. Percutaneous Achilles ten-don lengthening followed by below-knee walking casts has been reportedto yield positive results,23,36 though ithas been the author’s experience, aswell as that of Hall and associates,17

who treated a group of 20 childrenwho were persistent toe walkers withtendo-Achilles lengthening, thatpostoperatively some of the childrenstill walk on their toes. This wouldseem to fortify the assumption thathabitual toe walking is neurogenic inorigin rather than musculoskeletal.

SummaryHabitual toe walking has been

presented as a prolongation of anormal stage of development thatrequires conservative treatment toprevent or ameliorate associated gaitabnormalities such as tripping andfalling, as well as possible significantresidual ankle equinus. An approachto the evaluation of a child with toewalking should include (1) medicaland family history (prenatal, intra-partum, and postnatal), (2) gait eval-uation, (3) musculoskeletal exami-nation, and (4)neurologic examina-tion. Pathologic entities producingtoe walking have been explored inorder to differentiate those condi-tions from idiopathic (habitual) toewalking. The most common etiolo-gies of toe walking (non-habitual)would include gastrocsoleus equinusand cerebral palsy. Treatment of ha-bitual toe walkers might includeshoe therapy, orthosis therapy, au-ditory feedback, and surgery. ■

References1 Accardo P, Morrow J, Heaney MS, et al:

Toe walking and language development.Clin Pediatr 31: 158, 1992.

2 Accardo P, Whitman B: Toe walking asa neurodevelopmental marker for languagedisorders. Clin Pediatr 28: 347, 1989.

3 Aptekar RG, Ford F, et al: Light patternsas a means of assessing and recording gait. I:Methods and results in normal children. II:Results in children with cerebral palsy. De-volop Med Child Neurol 18:31-40, 1976.

4 Banks HH: Equinus and cerebral palsy:

Toe Walking...Con

tinuin

g

Medica

l Edu

catio

n


Dr. Caselli is Staff Podiatrist at the VAHudson Valley Health Care System AndAdjunct Professor, Department of

Orthopedic Sci-ences at the NewYork College ofPodiatric Medi-cine. He is For-mer Chairman,Department ofOrthopedic Sci-ences and Direc-tor, Departmentof Pediatrics atNYCPM.

B) Cannot walk backwardsC) Can stand with heels onfloorD) May take occasional heel totoe steps

6) Electromyographic studies ofhabitual toe walkers demonstrat-ed which one of the followingcharacteristics?

A) No different than that ofthe non-toe walkerB) Clonus with muscle activityat restC) Overlap of gastrocnemiusand anterior tibial activityD) Increased quadricepsactivity

7) Cerebral palsy is a primary dif-ferential for habitual toe walking.Which one of the following find-ings is most significant in makingthe diagnosis of cerebral palsy?

A) Constant tripping andfallingB) Beginning ambulation at28 monthsC) Severe in-toeingD) Low birth weight

8) Which type of cerebral palsy ismost commonly associated withtoe walking?

A) SpasticB) AthetoticC) AtaxicD) Rigid

9) Which of the following is notcharacteristic of pseudoscissorgait?

A) Internal tibial torsionB) Toe walkingC) Tripping and fallingD) Spastic muscles

10) Toe walking seen associatedwith mental retardation has been

1) Which one of the followingdisorders has not been found tobe associated with habitual toewalking?

A) Cerebral palsyb) SchizophreniaC) PoliomyelitisD) Muscular dystrophy

2) A history of fetal distress or hy-poxic episodes occurring shortlyafter birth is important since itcan indicate:

A) Autistic tendenciesB) Central nervous systemdamageC) Skeletal deformitiesD) Major joint instability

3) Obtaining a history of a child’sdevelopmental milestones is im-portant in assessing neuromotordevelopment. A child should beable to sit independently in ahigh chair by what age?

A) 3 to 4 monthsB) 6 to 7 monthsC) 9 to 12 monthsD) None of the above are cor-rect

4) The history of a habitual (idio-pathic) toe walker will usually in-clude which one of the following?

A) Slight delay in beginning towalk independentlyB) Begin toe walking 3-6months after beginning towalkC) Able to demonstrate heel-toe gaitD) Tend to trip and fallfrequently

5) Which one of the followinggait observations is not typical ofa habitual toe walker?

A) Normal angle and base ofgait

speculated to be due to:A) Tight posterior musclegroupB) HypotoniaC) Vestibular dysfunctionD) Poor coordination

11) Autistic children that toe walkhave been found to have all butwhich one of the following charac-teristics?

A) Early walkerB) Neurologically normalC) Toe walking combined withwhirlingD) Mentally defective

12) Which one of the following isa common finding in diastemato-myelia?

A) Neurological defects at birthB) Flatfoot deformityC) Neuropathic foot ulcerationsD) Symptoms improve withage

13) Which one of the followingtreatment modalities should notbe instituted in a child with mus-cular dystrophy?

A) Shoe therapyB) Ankle foot orthosis (AFO)C) Gait platesD) Auditory feedback

14) Which one of the followingdisorders is characterized by awaddling gait?

A) Spastic cerebral palsyB) AutismC) Duchenne musculardystrophyD) Diastematomyelia

15) The most important character-istic for a shoe to have in order toinhibit toe walking is a:

A) Straight last

Continuing

Medical EducationE X A M I N A T I O N

See answer sheet on page 177.



PM’sCPME Program

Welcome to the innovative Continuing EducationProgram brought to you by Podiatry ManagementMagazine. Our journal has been approved as asponsor of Continuing Medical Education by theCouncil on Podiatric Medical Education.

Now it’s even easier and more convenientto enroll in PM’s CE program!

You can now enroll at any time during the yearand submit eligible exams at any time during yourenrollment period.

PM enrollees are entitled to submit ten examspublished during their consecutive, twelve–monthenrollment period. Your enrollment period beginswith the month payment is received. For example,if your payment is received on September 1, 2001,your enrollment is valid through August 31, 2002.

If you’re not enrolled, you may also submit anyexam(s) published in PM magazine within the pasttwelve months. CME articles and examinationquestions from past issues of Podiatry Man-agement can be found on the Internet athttp://www.podiatrym.com/cme. All lessonsare approved for 1.5 hours of CE credit. Please readthe testing, grading and payment instructions to de-cide which method of participation is best for you.

Please call (631) 563-1604 if you have any ques-tions. A personal operator will be happy to assist you.

Each of the 10 lessons will count as 1.5 credits;thus a maximum of 15 CME credits may beearned during any 12-month period. You may se-lect any 10 in a 24-month period.

The Podiatry Management Magazine CPMEprogram is approved by the Council on PodiatricEducation in all states where credits in instruction-al media are accepted. This article is approved for1.5 Continuing Education Hours (or 0.15 CEU’s)for each examination successfully completed.

PM’s CME program is valid in all statesexcept Kentucky, Pennsylvania, and Texas.

www.podiatrym.com

B) High topC) Rigid soleD) Heel lift

16) Modifications that can be added to a shoe toimprove heel contact progression include all of thefollowing except:

A) High topB) 1/4 inch inner sole wedgeC) Heel liftD) Steel sole plate

17) Shoe therapy for habitual toe walking shouldbe instituted for:

A) 1-2 monthsB) 3-6 monthsC) 1-2 yearsD) Until toe walking ceases

18) Which one of the following orthoses has notbeen found helpful in inhibiting toe walking pro-gression?

A) Twister cableB) Gait platesC) Ankle foot orthosis (AFO)D) Heel lifts

19) Studies have shown that the following surgicalprocedure has been found effective in the treat-ment of toe walking?

A) Z-plasty of the tendo-AchillesB) Slide lengthening of the posterior tibial tendonC) Percutaneous Achilles tendon lengtheningD) None of the above

20) Based on this article, which of the followingstatements best describes habitual (idiopathic) toewalking?

A) Habitual toe walking is a totally benign con-ditionB) Habitual toe walking is a self limiting condi-tion that always resolves in early childhoodC) Habitual toe walking should be aggressivelytreated surgicallyD) Habitual toe walking warrants early conser-vative treatment to inhibit the toe walking pro-gression and reduce resultant ankle equinus

E X A M I N A T I O N

(cont’d)

Contin

uing

Medica

l Edu

catio

n

See answer sheet on page 177.

176 PODIATRY MANAGEMENT

Over, please

Continuing

Medical Education

Please print clearly...Certificate will be issued from information below.

Name _______________________________________________________________________Soc. Sec. #______________________________Please Print: FIRST MI LAST

Address_____________________________________________________________________________________________________________

City__________________________________________________State_______________________Zip________________________________

Charge to: _____Visa _____ MasterCard _____ American Express

Card #________________________________________________Exp. Date____________________

Note: Credit card payment may be used for fax or phone-in grading only.

Signature__________________________________Soc. Sec.#______________________Daytime Phone_____________________________

State License(s)___________________________Is this a new address? Yes________ No________

Check one: ______ I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be charged to your credit card.)

______ I am not enrolled. Enclosed is a $17.50 check payable to Podiatry Management Magazine for each exam submitted. (plus $2.50 for each exam if submitting by fax or phone).

______ I am not enrolled and I wish to enroll for 10 courses at $99.00 (thus saving me $76 over the cost of 10 individual exam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone.

Note: If you are mailing your answer sheet, you must completeall info. on the front and back of this page and mail with yourcheck to: Podiatry Management, P.O. Box 490, East Islip,NY 11730. Credit cards may be used only if you are faxing orphoning in your test answers.

TESTING, GRADING AND PAYMENT INSTRUCTIONS(1) Each participant achieving a passing grade of 70% or high-

er on any examination will receive an official computer form statingthe number of CE credits earned. This form should be safeguardedand may be used as documentation of credits earned.

(2) Participants receiving a failing grade on any exam will benotified and permitted to take one re-examination at no extra cost.

(3) All answers should be recorded on the answer formbelow. For each question, decide which choice is the best an-swer, and circle the letter representing your choice.

(4) Complete all other information on the front and back ofthis page.

(5) Choose one out of the 3 options for testgrading: mail-in,fax, or phone. To select the type of service that best suits yourneeds, please read the following section, “Test Grading Options”.

TEST GRADING OPTIONSMail-In GradingTo receive your CME certificate, complete all information and

mail with your check to:Podiatry Management

P.O. Box 490, East Islip, NY 11730There is no charge for the mail-in service if you have already

enrolled in the annual exam CPME program, and we receive this

Enrollment/Testing Informationand Answer Sheet

exam during your current enrollment period. If you are not en-rolled, please send $17.50 per exam, or $99 to cover all 10exams (thus saving $76 over the cost of 10 individual exam fees).

Facsimile GradingTo receive your CPME certificate, complete all information and

fax 24 hours a day to 1-631-563-1907. Your CPME certificate willbe dated and mailed within 48 hours. This service is available for$2.50 per exam if you are currently enrolled in the annual 10-examCPME program (and this exam falls within your enrollment period),and can be charged to your Visa, MasterCard, or American Express.

If you are not enrolled in the annual 10-exam CPME pro-gram, the fee is $20 per exam.

Phone-In GradingYou may also complete your exam by using the toll-free

service. Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Mon-day through Friday. Your CPME certificate will be dated thesame day you call and mailed within 48 hours. There is a $2.50charge for this service if you are currently enrolled in the annual10-exam CPME program (and this exam falls within your enroll-ment period), and this fee can be charged to your Visa, Master-card, or American Express. If you are not currently enrolled, thefee is $20 per exam. When you call, please have ready:

1. Program number (Month and Year)2. The answers to the test3. Your social security number4. Credit card information

In the event you require additional CPME information,please contact PMS, Inc., at 1-631-563-1604.

E N R O L L M E N T F O R M & A N S W E R S H E E T

✄

177

Contin

uing

Medica

l Edu

catio

n

E N R O L L M E N T F O R M & A N S W E R S H E E T (cont’d)

✄


LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educational objectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

EXAM #9/02Diabetes Related Neuropathy

(Rehm)

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educational objectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

EXAM #10/02Toe Walking

(Caselli)

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

habitual toe objectives walking - podiatry m · solely as habitual toe walkers exhibit a slight...

Documents