Friday, May 27, 2022

Idiopathic Toe Walker

Molly Pitcher

Dear list,

Below is my original question and the replies. Thanks to all who


I am looking for some information on idiopathic toe walkers.

What types of orthoses are you using?

Is anyone familiar with any articles on the subject?

It seems there are many different opinions on how to treat the problem

if treated, from casting below and above the knee, DFA/AFO, hinged

AFO’s, extended toe plates.

There are three pediatric orthopedists in my community with three

varying opinions. I will post my answers. Thank you for your

assistance. Molly Pitcher, C.P.O.

The protocol we’ve used here is typically art. AFO’s with p.f. stops at

0degrees and full dorsiflexion allowed. No footplate modifications a few stubborn cases the orthopod has serially casted and in

some cases had to resort to T.A.L. Sx.

In response to your posting can I suggest that you pay a visit to the

RECAL Information Services website


RECAL Information services specialises in the provision of guides to the

literature in prosthetics, orthotics, physical medicine and

rehabilitation. Our services aim to keep the clinician, research worker

and rehabilitation professional in touch with the published literature

in a variety of easy to use and convenient formats.

The ITW’s that I see are typically severe. (20+degrees of plantar

flexion.) I have managed them all successfully with

an OOS AFO with a wedge built into the base. They return every 2 weeks

for evaluation and usually I take off about 5 mm. Once I’ve gotten them

plantargrade, they go into an articulated AFO of polypropylene with a

plantar flexion stop.

Assuming the child can range to neutral (sagittally), anything that

limits the ability to aggressively plantarflex will work. As with most


(mafo’s in the local vernacular), the ability to keep the child in the

orthoses is the answer. The orthosis should be sufficiently strong and

utilize a buckle/strap combination with an appropriately directed force

application to have any chance of working. I’ve found that 2-4 degrees

of dorsiflexion works well. It is simply too difficult for the child to

stand and does work pretty well. Of course there is always the child

that postures in such a way that he “overrides” the merits of the system

he’s in. Iv’e some fundamental problems with the Cascade DAFO system

but they do possess marketing genius! The design that goes up the

posterior calf but has no proximal strapping or joints is a design that

I’ve used for years… They gave it a name (or number, I should say…)

and it works really well! As you know, when articulating a mafo, alot

of frontal plane control is lost due to the need for malleoli clearance.

This design allows for unimpeded dorsiflexion (no anterior strapping at

the calf) but excellent frontal plane control.

Molly, In our area the primary method of treatment is with TPE AFOs.The

next most common method is with TPE SMOs.

I look forward to your post of responses.

JBJS in the last year had a good article on ITW. Check it out. If you

can’t find the article let me know.

Hi Molly: How old is the child? Has it been definitively determined no

underlying pathology exists? Is the child walking full time, cruising or

just pulling up? If walking is the toe walking intermittent or constant?

And finally what is the passive knee extended then knee flexed range to

R1 and R2?

Molly I have used hinged AFO’s to prevent the kids from getting on the

toes. This seems to work well. They can still do it but it takes some

doing. Last week I delivered a novel design approach to the toe walker

problem with a heavy metal shank in the shoes. This was prescribed by a

pediatrist. The young boy still was on his toes in the office. Time

will tell.

I was one as a kid, so on that basis I will reply. My shoes were built

up with about 1/4″ lateral wedges under the forefoot. I had a LOT

of leg stretching exercises to do over the years and that was the prime

thrust of my treatment. That was in 1964 to 1972. Undoubtedly, things

have changed a bit since then.

Molly Pitcher wrote: How old were you when this was done? Do you

remember whether it was successful or did you just stop toe walking? Did

other family members toe walk?

His answer: All this started before I remember. My earliest

recollections were about age 5. It was moderately successful because I

can put my heel on the floor when I walk, but I have still quite a

spring in my step, so my heel comes off the floor prematurely according

to traditional gait analysis. One other problem is that I have huge

gastrocs and soleus muscles and they make it hard to walk normally

because the ankle dorsiflexers are easily overpowered and thus fatigued.

Strengthening the muscles in the anterior compartment does help,but not

as much as you would expect. I have a daughter aged 5 and she does

not toe walk.

In response to your query about Idiopathic toe walkers, I have been

successful in using many different AFO designs, as long as it restricts

plantarflexion. At this point in time I am heavily relying on the

Cascade DAFO #3 (hope I got the number right !) It has an open anterior

at the tibia to allow dorsiflexion, but still blocks excessive

plantarflexion. The wrap around design on the mid and hindfoot helps

keep the heel down which can be a problem. Finally, it is thin, light

and colorful, which can’t hurt. If you are going to fab. it yourself,

may I suggest that many professionals in the field recommend including

tone reduction modifications on the plantar surface, a firm way of

anchoring the instep down, and to try to get a little dorsiflexion

(maybe 3 degrees) range if the patient has it. I suspect both solid or

articulated will work, but if there is much medial / lateral laxity, the

solid may get a better grip on the hindfoot.

If the patient has the range of motion to use it and/or is getting good

PT, I usually articulate an AFO. I haven’t had good results with

extended toe plates. Children are very adept at overcoming little

inconveniences like that in different ways (balancing on the toes of the

shoes, externally rotating at the hip).

If it is really idiopathic, we usually do casting if heel cords are

tight, followed by hinged AFOs if needed for maintenance. Watch for


proximal muscle weakness, probably get a neuro or PM&R exam to confirm

diagnosis (though might treat similarly if can walk OK in the cast of



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