Dear list,
Below is my original question and the replies. Thanks to all who
responded.
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
used.in 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
96 http://www.recal.org.uk.
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
afo’s
(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
subtle
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
HAFO…)
