1
Point during gait cycle when foot transitioning between phases
Rocker
Which rocker:
After heel strike at initial contact when foot progresses into PF
First rocker
Which rocker:
Late stance and push off phase as foot moves from DF into PF to push off
Third rocker
Which rocker:
During mistance when tibia advances over foot and pushes ankle into DF
Second rocker
Name the rockers in order that are most affected during idiopathic toe walking?
1, 2, 3
- Diagnosis of exclusion
- Walks on toes without known reason or pathology
- Can be intermittent or constant
- Familial? Genetic component 30-42% of children
- Various stages of early ambulation
- prewalking skills to within 6 months after start of independent walking
- Historically: periods of toe walking normal component of development up to age 3 (not common thought)
Idiopathic toe walking
- Pain
- Calluses or foot skin redness
- Muscle tone
- LE ROM
- Muscle length tests
- Leg length
- Deep tendon reflexes
- Clonus
- Babinski reflex
- Gait pattern
- Ankle/foot alignment
- LE and trunk strength
- Gross motor function
- Sensory dysfunction
- Thigh-foot angle
Objective for ITW
What are the (2) daytime orthotic requirements?
1. Toe walking greater than 25% of the time
2. Need to maintain ROM and gait gains following serial casting or surgical intervention ***
What is the biggest co-morbidity that ITW will have?
77% of children who walked on their toes had a speech delay **
What are we thinking if the child does not toe walk for the first 6 months and then they start suddenly?
Not toe walking.... but dont know what it is (possibly muscular dystrophy)
- Stretching: ankle PF, hip flexors, hamstring musculature
- Strengthening: ankle DF, ankle PF, hip abductors, trunk
- Joint mobilization
- balance training
- gait training
- motor control
- electrical stimulation
- Sensory based interventions
- serial casting
- orthotic management
PT interventions - conservative
- Nightime splinting
- Night stretching AFOs combined with knee immobilizers
- Prolonged, static stretch of the gastrocnemius
- Daytime orthotic
- Orthotic interventions
- AFOs
- Supramalleolar orthoses
- Shoe inserts
- Carbon foot plates
Stretching for ITW
T/F: tendon lengthening promotes normal gait pattern?
FALSE... does not promote normal gait pattern
Which category of tx options:
- Traditional stretching and strengthening protocols may not be effective in increasing ROM
- Serial casting may be the best option to improve ankle ROM
ROM less than or equal to 0 degrees **
Which category of tx options:
- Daytime, articulating AFOs with weaning to use of carbon footplates
- Exercise
- Stretching
- Strengthening
- Gait training
- Balance training
- Auditory feedback (soccer squeaker)
- Manual therapy
Greater than 10 degrees of DF with knee extended
- Past medical history
- Acquisition of developmental skills
- Possible familial history
- Prior tx
- therapy
- Medical/surgical interventions
- Planned future interventions
Evaluation with ITW
Which category of tx options:
- Night stretching and bracing
- articulating AFO
- therapeutic exercises: stretching, strengthening, gait training, and balance training
Ankle DF ROM 5-10 degrees of DF with knee extended
- PF in stance and swing phases of gait
- Shorter step lengths
- Increased anterior pelvic tilt
- Knee hyperextension
- Excessive midfoot pronation coupled with hindfoot eversion and/or toeing out during stance phase
- Frequently lack first and second rockers
- Decreased third rocker
- Early heel rise **
Gait deviations with ITW
1. PF contracture with hard end feel
2. PF contracture nonresponsive to serial casting
3. Underlying orthopedic comorbidities
Consult with orthopedics for potential surgery/tendon lengthening for ITW
- CP
- Peripheral neuropathy
- ASD
- Hereditary spectrum disorder
- Spinal cord disorders
- Neuromuscular/muscular dystrophies
- Orthopedic concerns
- McArdle disease
Differential diagnosis for ITW
This procedure fixes toe walking by getting feet flat, but will not have normal gait with push off --> Biomechanics are off now because you've changed the pull of the tendon
Tendon lengthening surgery
Which category of tx options:
- Night splinting
- PT
- Manual therapy
- Therapeutic exercise: stretching, gait training, and balance training
Ankle DF ROM 0-5 degrees