How To Address Conditions That Affect Pediatric Gait
Q: What is your treatment plan for children with idiopathic toe walking syndrome? A: Dr. Harris calls idiopathic toe walking a diagnosis of exclusion. “These children walk on their toes from the time they begin walking and will come down on command,” he comments. “However, as soon as they are distracted, they revert to toe walking.” Dr. Harris notes these children initially have an adequate range of ankle dorsiflexion but tend to develop contracture of the triceps mechanism over time. Likewise, Dr. Valmassy also rules out other potential ideologies for the clinical presentation. He emphasizes ruling out any neurological involvement or congenital tightness of the posterior muscle group when evaluating these children. Dr. Keen varies her treatment according to the age of the patient at presentation and the severity of the idiopathic toe walking. For a beginning walker, utilizing a shoe with a stiff sole is often very beneficial for a young child with minimal body weight, according to Dr. Valmassy. As he explains, the shoe will force the heel to the ground and actively stretch the posterior muscle group with each step. As a child becomes older, heavier and stronger, he says the ability of the stiff shoe becomes less beneficial. When this occurs, Dr. Valmassy frequently sends these children and their parents to a physical therapist for one session to develop a home exercise program. He adds that a short course of serial plaster mobilization may also be effective for these children. Dr. Harris says treatment for these children begins with a physical therapy assessment and the development of a home program for stretching. When these children have mild contractures, Dr. Keen suggests a stretching program that involves using the stairs or a kitchen ladder or kitchen stool as a fulcrum at the metatarsal heads. Dr. Harris adds that physical therapists are very adept at identifying a subtle increase in muscle tone that may not be apparent when the physician examines the patient in an office setting. When a child has a normal range of ankle motion, Dr. Harris will utilize a solid ankle AFO. Dr. Keen notes that very young children who cannot stretch or consistently follow cues need nighttime or full-time (most of the day and night) splinting. She advocates the use of AFOs at night and during the day, or using an AFO in the day and a splint at night. Dr. Harris adds that using an AFO can help retrain gait to a heel to toe pattern and prevent the development of contractures. Dr. Keen also emphasizes the importance of gait training with a pediatric physical therapist. She says techniques such as walking backward forces the use of dorsiflexors as does heel walking, which can be fun parts of home programs if siblings are involved. For a child without an adequate range of motion at the ankle, Dr. Harris begins employing serial stretching casts in an attempt to achieve at least 10 degrees of ankle dorsiflexion with the knee extended. If one cannot achieve an adequate range of motion, Dr. Harris says the child is a candidate for surgery. He finds that most children who require surgery have a fixed equinus below neutral that is not altered by changing knee position. He prefers a Hoke percutaneous tendo-Achilles lengthening and subsequent use of a protective solid ankle AFO for four to six months. Q: How do you select patients for serial casting? A: “It is unclear exactly how serial casting works,” says Dr. Harris. “At one time, it was thought that it increased ankle range of motion by reducing tone. This led to the concept of tonal reduction or inhibition casting. After experimenting with this technique on and off over several years, I have become convinced that it does not produce any permanent alteration in tone. I suspect that additional range of motion is achieved by weakening the muscle through disuse.” Dr. Valmassy’s selection is based on the extent of the deformity and the child’s ability to stand, bear weight and walk in an efficient fashion. “I find that the earlier the casting is implemented, the more successful it is,” he says. Often, Dr. Valmassy will use serial casting for children who are ambulatory as well but he notes that patients often do not tolerate this well.