Given that toe walking and other gait disturbances are common among children, these expert panelists take a closer look at these conditions, offer keys to the diagnostic assessment and share their insights on appropriate treatment modalities and physical therapy regimens.
Q: What is your treatment plan for children with diplegia and hemiplegia?
A: Mary Keen, MD, says most children with diplegia and hemiplegia walk so she strives to facilitate independent ambulation. In order to achieve safe, efficient ambulation, Dr. Keen says children need adequate balance, adequate core strength, endurance and functional range of motion in both lower extremities. She says her treatment plan addresses these areas of function but the approach varies with each child.
Each component generally requires skilled physical therapy and a home program of exercises, which Dr. Keen and the physical therapist(s) determine. Dr. Keen says the home program may include things like wearing Lycra garments for core strengthening and using electrical stimulation for specific muscle strengthening. Dr. Keen notes that such a program always includes stretching (preferably not passive). This usually involves a variation of the “runner’s stretch” and long sitting for a prolonged and full hamstring stretch, according to Dr. Keen.
Another mainstay of her treatment plan is nighttime splinting until growth is complete. She often employs knee immobilizers with nighttime foot/ankle splints to stretch the entire length of the gastrocsoleus during sleep.
Ronald Valmassy, DPM, says the overall goal in treating these patients is establishing some stability and simultaneously preserving as much normal function and motion as possible. In most cases, Dr. Valmassy says this will involve using a functional foot orthosis or UCBL to restrict foot position and motion. He adds that this “would certainly be appropriate in milder cases in which significant compensation is occurring in the foot.” In other cases, Dr. Valmassy says a supramalleolar orthosis or an ankle foot orthosis (AFO) would be beneficial in allowing these children to ambulate with greater stability.
Initial treatment for both of these conditions depends on the adequacy of dorsiflexion of the ankle, status of the knee and status of the hip, according to Edwin Harris, DPM. He notes that most of these children have spasticity as a component of their movement disorder and are likely to have a “dynamic” contracture. As long as one can achieve 5 to 10 degrees of ankle dorsiflexion with the knee in extension, Dr. Harris says one can manage these children in AFOs. If not, he advocates trying to achieve an adequate range through physical therapy. Dr. Harris notes this physical therapy is an ongoing process and caregivers must undertake most of it at home on a daily basis.
Equinus deformity is common to both diplegia and hemiplegia, points out Dr. Harris. He says hemiplegics are more likely to have equinovarus deformity while diplegics often have equinovalgus deformity. To maintain foot correction, Dr. Harris says AFOs must have well molded foot components. In general, he initially prefers solid AFOs for children, who tend to tolerate them better.
Dr. Keen says serial casting or the combination of Botox and serial casting is sometimes necessary to achieve and/or maintain a functional range of motion in the affected hamstrings, gastrocsoleus and/or posterior tibialis muscles. Dr. Harris concurs. If dynamic contractures prevent bracing, Dr. Harris suggests administering Botox to the gastrocnemius and subsequently employing serial stretching casts to improve range. In some cases, he notes serial stretching casting alone will lead to a good result.
Fixed unyielding contracture at the ankle will probably require surgery, according to Dr. Harris. If possible, he suggests delaying this until the child is 6 to 7 years of age. Dr. Harris says surgical options include gastrocnemius recession, gastrocsoleus recession and tendo-Achilles lengthening. One would determine the procedure of choice via the physical examination. Dr. Harris cautions that diplegia and hemiplegia are four joint level pathologies that involve the hip, knee, ankle and subtalar joint complex.
“It is inappropriate to attempt to manage ankle equinus without properly addressing knee and hip flexion deformity,” notes Dr. Harris.
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. He prefers using a night splint for children in whom he has initially utilized casting. When he does not choose serial casting, Dr. Valmassy uses night splint therapy.
Dr. Keen will use serial casting for mild contractures that do not respond to a stretching program and for patients who will not tolerate nearly full time splinting. For more severe contractures, she usually recommends serial casting as a first step and then nighttime splinting for maintenance.
“I have been surprised how effective this treatment plan can be,” recalls Dr. Keen. “I had one 12-year-old patient with worse than 45 degree plantarflexion contractures (therefore missing 65 degrees of normal ROM) respond to serial casting and maintain it for more than a year.”
For serial casting to be safe and successful, Dr. Harris says one must meet several criteria. He says the child must be sensate and verbal enough to express pain if something happens under the cast. The equinus contracture should not exceed -15 degrees. In addition, Dr. Harris says contracture should not be so rigid that the only way to achieve dorsiflexion would be through destructive compensation through the midfoot. Finally, the child ideally should be ambulatory, according to Dr. Harris.
Q: What are your indications for stopping orthotic therapy?
A: Dr. Valmassy typically looks for an improvement in the overall range of motion as well as an improvement in overall foot position and foot function before stopping orthotics. He notes that if a child can function in an asymptomatic fashion without any signs of compensation, then it would be appropriate to stop orthotic therapy.
Other rationale for stopping orthotic therapy would involve the underlying problem becoming worse. In these cases, surgical intervention may become an appropriate adjunctive therapy, says Dr. Valmassy.
In regard to stopping orthotic therapy, Dr. Keen says there is generally a weaning process of weeks to months to ensure the child maintains gains with ongoing growth. First, she will discontinue daytime splinting since it is “generally what the child wants.
“Children will usually agree to nighttime splinting if it means they can do without it during the day,” points out Dr. Kern.
For children with diplegia and hemiplegia, Dr. Harris says most are going to remain in orthoses for a very long time as they remain at risk for development of contracture at least until they achieve skeletal maturity. Due to the functional gains these children experience with bracing, he notes many of them will prefer to continue bracing since it makes walking easier.
Many children with a mild deformity will stop wearing bracing during their later teenage years but Dr. Harris tries to convince them that it is advantageous to use bracing at least at night. He says most patients “continue in some form of bracing indefinitely.”
Idiopathic toe walkers need to retrain themselves with orthoses, which also prevent contractures, says Dr. Harris. He would not consider stopping orthoses for at least six months and if possible, would try to get patients to wear orthoses for the life of the orthosis, which is probably about a year.
Q: What do you do if orthosis therapy maintains a range of motion but does not restore a heel-to-toe gait pattern?
A:In such cases, Dr. Valmassy evaluates the child to determine whether any compensatory changes have occurred and if there is any symptomatology. He may continue using an orthotic device as the child continues developing.
“The first thing that I would consider is that I have made a bad therapeutic decision,” says Dr. Harris.
As he points out, the existence of a functional or static hip and knee flexion deformity may explain why the child in question can maintain a range of motion with an AFO but is still walking on the toes. Although this is unlikely to occur with idiopathic toe walking syndrome, Dr. Harris notes it is extremely common in cases of spastic hemiplegia and diplegia.
If the child has a corrected gait in an orthosis but reverts to a toe-heel or toe-toe pattern without the orthosis, he or she is probably a candidate for an appropriate lengthening of the triceps mechanism, according to Dr. Harris.
As for paralytic dropfoot, Dr. Harris notes that using an AFO can help convert a child with paralytic anterior compartments from a toe-heel gait to a heel-toe pattern. Unless the paralytic process is somehow reversible, he says he would expect lifetime brace wear for this patient.
Dr. Harris is a Clinical Associate Professor in the Department of Orthopaedics and Rehabilitation at the Loyola Medical Center in Maywood, Ill. He is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Keen specializes in pediatric physical medicine and rehabilitation.
Dr. Valmassy is a Staff Podiatrist at the Center for Sports Medicine at St. Francis Memorial Hospital in San Francisco. He is a Fellow of the American College of Foot and Ankle Orthopedics and Medicine. Dr. Valmassy is also a Diplomate of the American Board of Podiatric Orthopedics and Primary Podiatric Medicine.