22 year old idiopathic toe walker - results

22 year old idiopathic toe walker - results

Clinical Orthotic Consultants

2/24/2015

Below are the replies to my original question...

 

I have been dealing with idiopathic toe walkers for several years...vast
majority start 3-5 years of age, and I have had good success with the Kevin
Matthews SMO design.

I had a 22 year old female, toe walk into my office today. Off at
university, bright young lady, has been on her toes as long as she can
remember. Wears heels or wedge shoes most of the time to hide the toe
walking. First issue is that I am not sure she wants to walk normally

(mom is on her about this of course). If she is not interested then I am
not going to intervene. She does have normal ROM at ankle...heavy
callousing on forefoot, no orthopedic issues (yet). Mom is
concerned...daughter no so much.

Question would be...

Have you treated a 22 year old adult with any bracing to prevent the toe
walking habit? If so, what devices are you using? How long was
treatment...did it work?

 

Just got back from academy meeting in New Orleans. One of the talks was
about ideopathic toe walking. I am an Orthotist/Prosthetist working at
Shriners hosp for the past 36 years and have seen a fair amount of these
kids. At the meeting Dr Mark Geil gave a presentation on the topic. He had a
patient that was an IP toe walker that when the child stepped on a different
surface would walk differently. He noticed when the child walked on a mat
with simulated granular pebbles the child walked with a heel toe gait. With
that said we have also found that some children respond tactically when
walking on different surfaces. We had a parent tell us that her child always
walks on his toes until he goes into a mulched area of a playground. Ask the
patient if there is a surface she prefers or when she walks on it her foot
comes down.

On the one child we made a ucb and artci afos. The child when wearing the
afo's still got the heel off the ground a little by crouching however on
command we would get a better step. With the UCB we made an extension off
the back of the ucb about 1/2 wide extending approx. 4- inches with a
small pelite pad at the end. When the child walked and the posterior pad
approximated his calf when he got on his toes , his heels came down. We feel
that the tactile sensation he had received at the back of his calf
facilitated the heel toe gait and it was amazing. (not sure if it was
because it was more uncomfortable, we didn't make it to hurt only to provide
a stimulus to withdraw, perhaps it just made it easier to walk without that
sensation) The caveat was that this child had a somewhat mild case of
autism.

In summary there is a belief that tactile stimulation either that it is too
overwhelming when the foot was down or not enough is possibly a reason. I
have never had an adult with this condition but it would be interesting to
fool around with these types of things.

----------------------------

We look after the younger age group kids (usually under 10) from a Physio
led Toe walking clinic we have here. We mostly use carbon foot plates and
occasionally AFOs - if they don't respond. Also tried night resting AFO's -
particularly after a casting session.

Also in conjunction with the ortho team serial casting can be beneficial -
one cast for 4 weeks at best Dorsiflexion you can get - no need to serial as
not treating spasticity of course.

I have valso heard and will be interested in the list group experiences that
sensomotoric style foot orthoses work well - I'm interested in exploring
this option if anyone has used with results.

 

Look forward to all your replies - an interesting topic.

 

I have used several orthotic designs with good success in adult toe walkers.
I tend to lean towards using the Elaine Owens gait training orthosis design,
which was initially used to increase ROM in patients with tight heel cords.


 

For toe walking - treatment begins with an articulated AFO set in
plantarflexion with a heel post to neutral. I then work with the therapist
to retrain the patient's gait. By posting the AFO to neutral, it forces the
patient to have a heel strike, even with the ankle in plantarflexion. By
creating this heel strike, we have normal tibial progression, with
reciporcal knee and hip flexion/extension; we are creating normal gait
mechanics. Over several weeks, we remove parts of the heel posting and
increase the plantar flexion stop, bringing the patient down off of their
toes. After several weeks (up to 6 months) the patient's gait should be
retrained and toe-walking should occur minimally, if at all.

 

I am working to collect data on patients at this time, so everything I've
seen so far, is anecdotal. I've used it on a total of 4 patients with
success. The oldest is in her 40s and she is currently doing well.

 

After all this explanation, if the patient is not willing to commit her time
and energy towards wearing AFOs and attending therapy, I do not see
potential for success.

 

   I am very happy to see a toe walking walking question come across the
list serve. I too have a good deal of experience treating adolescent and
pediatric toe walking but the latest I have personally treated were
teenagers at the latest. I had resources available to me to utilize botox,
serial casting and intense PT. I realize this is more a recipe for non
ideopathic toe walking but the point is that toe walking is not something
that can be cured with orthotics only. Your gal will obviously cease to toe
walk while wearing any AFO that limits plantarflexion but undoubtedly she
will revert to her toe walking as soon as an AFO is removed.

  I really have doubts that a lifelong gait deviation can be eliminated from
someone who is 22 years old. She would have to be the most motivated
individual in the world and it would seem that she already lacks in that
department. I think you would be wise to recruit a PT that has toe walking
experience. You very well could make a wonderful AFO but if someone doesn't
address the gait training and sensory aspects of the problem an AFO doesn't
go very far. I wish you the best of luck with this endeavour. It makes you
wonder, why didn't anyone address this gait issue before now?

 

I had a 56 yr./old male toe walker. Fit him in Articulated AFO's and
progressively reduced his ankle alignment as his tendon's stretched out. He
eventually did get an Achilles lengthening a year later to gain the extra 10
degrees. A little different case but it's uncommon to have adults that toe
walk.

 

I have also messed with carbon foot plates with the younger kids whose
parents will not put them in plastic AFO's. The toe plate does not allow
them to extend their toes and hence no toe walking. You may have already
thought of this.

 

 

 

 

Derek Kozar M.Sc., C.O.(c)

Certified Orthotist

Clinical Orthotic Consultants of Windsor, Inc.

316-3200 Deziel Dr.

Windsor, ON

N8W 5K8

519-944-8340 W

519-944-8360 F

519-982-1747 C

www.cocwindsor.com