Idiopathic Toe Walking and Bracing
by Andy Albrecht, DPT, PCS
Kids Place Central Clinic Manager
Idiopathic toe walking has long been a diagnosis pediatric physical therapists have difficulty treating. On the surface, it seems straight forward. A child has tight gastrocs (calves) and therefore walks on her tippy toes. By stretching out the calves, the child is able to touch the heel to the ground and improve their gait (walking) pattern. Success! – the child would walk with a nice heel-toe gait pattern. But then upon re-examination one or two weeks later, the child would be up on their tippy toes once again. Frustration sinks in – for me, the child, and their family – with the decreased longevity of carry-over.
For the longest time, there was minimal research into the best course of treatment for children who walk on their toes. Recently, I was able to attend a course spanning over two weekends fully devoted to the topic of idiopathic toe walking. Finally, I feel as though I gained some traction into the best treatment of children who toe walk. I could go on for quite some time about the different evaluation and treatment techniques for children who toe walk, but I would rather look into the role of orthotics in the treatment of children who toe walk.
Orthosis is defined as “an externally applied device used to modify the structural and functional characteristics of the neuromuscular and skeletal system (ISO 8549-1:1989).” Devices are usually prescribed to control, guide, limit, or immobilize an extremity, joint, or body segment. When looking specifically at orthotic management for the treatment of children who toe walk, we recommend two separate devices.
The first is a foot orthotic to control the pronated or “flat feet” that are commonly seen in children who walk on their toes. These inserts are typically worn on a daily basis to help control the alignment and stability of the foot to improve biomechanics and alignment of the legs.
The second device is an Ankle-Foot Orthosis (AFO). An AFO is a device the controls the ankle and foot running along the side and bottom of the foot, up the ankle, and ends below the knee joint. Most AFOs have an angle of the ankle set at 90 degrees (think of a right angle where your lower leg and foot meet). However, if a child presents with decreased ankle range of motion, it could be painful and/or detrimental to set the angle of this ankle this way.
Think about it this way – your calves are tight enough you can’t touch your heel to the ground. Then, you force your ankle to be at a 90-degree angle in an external device. Inevitably, there will be some compensation elsewhere in your body. Often times we will see pressure spots developing along the foot and ankle of a child with an AFO set up this way.
Another negative side effect is the child walking with their knees bent throughout the gait cycle. This is because the gastrocnemius is a muscle that crosses both the ankle and the knee joint. If the muscle is pulled to the extreme at the ankle, it will be tight enough to not allow the knee to straighten fully (fun little anatomy lesson for you!). For this reason, it is recommended that the angle of the ankle in the AFO (AA-AFO) be set in an appropriate amount of plantarflexion (pointing your toes). While this may sound counterintuitive, it has been shown time and time again to improve the child’s gait pattern.
In addition to having a plantar-flexed AA-AFO, the AFO is also inclined to improve the properties of a child’s gait pattern. This is because children who walk on their toes maintain the tibia (one of the bones between the knee and ankle) in a reclined position.
To illustrate this, try standing on your tippy toes. Now, without allowing your ankle to bend, put your heels on the ground. You should now be standing with your knees locked back (or hyperextended) and your trunk leaning forward. The position of the bone between your ankle and your knee is reclined from a vertical axis. Children who walk on their toes maintain this reclined position of the tibia throughout the gait cycle. In a typical gait pattern, the tibia must go through several important moments of achieving a vertical and inclined position. For this reason, an AFO should have an inclined position to allow for the appropriate timing of muscles and strengthening during the gait cycle.
Depending on the discussion between your physical therapist and orthotic specialist, these AFOs may be worn all day or for an hour of purposeful walking per day to improve the timing of muscles and gait pattern. As with any new skill, practice makes permanent. By walking with AFOs we are allowing for repetition after repetition of improved gait pattern allowing for stronger carry-over to improved gait pattern without the AFOs being worn.
This treatment technique is just a tiny sliver of the over arching picture to successful treatment of children who walk on their toes. If you have any questions, feel free to talk with your physical therapist or e-mail me directly!