Toe Walking Treatment & Management
- Author: Ryan Krochak, MD; Chief Editor: Jason H Calhoun, MD, FACS more...
Nonoperative treatment of toe walking includes stretching, casting, orthotics, and chemodenervation with botulinum toxin. The success of such treatment depends on the age of the patient, the severity of the equinus deformity, and the underlying etiology.
Stretching is often the first treatment attempted for toe walking because it is the least invasive. It is recognized that stretching and physical therapy offer a limited chance of success for treating idiopathic toe walking (ITW), and it is more often used in an attempt to maintain range of motion gained by other methods. Stretching must use the patient's body weight, since the lower extremity muscles are too powerful to allow effective passive stretch by parents or therapists. In one technique, the child is stood with the forefoot elevated on a small block so that the heel may drop downward. The parents steady the child and add gentle pressure to the stretching process. In a second technique, the patient leans forward against a counter, with feet together and pointed straight forward, knees straight, and hips extended. Progressive stretch is accomplished by increasing the distance from the counter.
Serial casting is another nonoperative technique for stretching the Achilles tendon. The child is placed in a below-the-knee plaster or fiberglass cast while the knee is flexed and foot is dorsiflexed, most easily done with the child prone and while an assistant pushes gently downward on the forefoot. Once the cast has set, the gastrocnemius component stretches further as the knee extends. These casts are changed weekly or biweekly to progressively increase the range of dorsiflexion. Between cast changes, the child can walk with the use of cast shoes.
A custom orthotic such as the articulated molded ankle-foot orthosis (AFO), as seen in the image below, is another option for nonoperative treatment. This appliance is cosmetically acceptable, fits in a regular shoe, allows nearly normal ambulation, and prevents plantarflexion while allowing full dorsiflexion with every step. An AFO in a growing child can be expected to fit for 12-18 months before requiring replacement.
For toe walking due to muscle spasticity, stretching alone is ineffective. Serial casting can be used to lengthen the Achilles tendon, but the contracture recurs rapidly unless the patient is maintained in an AFO. An articulated molded AFO used consistently is an effective appliance for preventing the progression of spastic equinus that occurs with growth. If a patient with spasticity continues to toe walk when AFOs are discontinued after the patient reaches skeletal maturity, operative lengthening may then be considered so that the orthosis can be discontinued. After skeletal maturity, equinus in a patient who is spastic is less likely to recur.
Chemodenervation of the gastrocnemius-soleus complex muscles with botulinum toxin is another method of nonoperative treatment. Botulinum toxin causes temporary (approximately 3 months) selective muscle paralysis by blocking acetylcholine release at the neuromuscular junction. It was first introduced in the early 1990s as an injection into the gastrocnemius muscle in an attempt to decrease tone in patients with cerebral palsy. Subsequently, its suggested indications have expanded to ITW, but most studies have demonstrated little efficacy to this approach.
For toe walking associated with paralytic muscle disease, the use of regular stretching and orthoses together should be considered while the child remains ambulatory. Both modalities of nonoperative treatment are preferable to operative lengthening, as the latter weakens the muscle and interferes with ambulation. Prolonged use of serial casts also weakens muscles and should be avoided.
If conservative measures fail to correct idiopathic toe walking (ITW) after about 12 months, operative lengthening is considered. Indications for Achilles lengthening include ankle equinus that exists both with the knee flexed as well as extended and interferes with gait. This procedure can be performed under a brief anesthetic by either an open or percutaneous technique.[13, 34]
An open heel-cord lengthening is performed through either a medial incision approximately 6-8 cm in length or a transverse incision at the level of the malleoli. A straight, longitudinal posterior incision centered over the tendon is avoided in order to decrease the risk of wound dehiscence and because the skin scar may contract and limit dorsiflexion. The tendon sheath is opened, and the tendon is incised longitudinally over the full length of the exposure, dividing the tendon into 2 equal halves. One half is detached proximally and the other half distally in a Z fashion. The two halves of the tendon are then sutured back together at the desired length. Following the procedure, the patient is immobilized in a below-the-knee cast for approximately 6 weeks.
A percutaneous rather than open lengthening of the Achilles tendon is also an option for most patients with ITW. To perform this technique, an assistant holds the patient's foot and ankle in maximum dorsiflexion after the skin is prepared. A thin-bladed tenotomy knife is inserted through a small medial stab wound 5-8 cm above the calcaneal insertion, depending on the size of the patient. By feel, the medial half of the proximal tendon is divided. A second medial stab wound just above the distal insertion is made and the anterior half of the tendon is divided. If the tendon has rotated a full 90º over this length, half of the fibers have been cut proximally and the other half have been cut distally. The assistant feels the tendon give, and the equinus contracture may then be corrected.
The amount of correction is controlled by immobilizing the foot and ankle in a below-the-knee cast in the desired position. If the tendon fails to part with 2 incisions, a third stab wound is made from straight posterior, halfway between the first 2 incisions. Through this, the lateral half of the fibers is cut until the tendon gives.
Open and percutaneous techniques are also applicable to patients with toe walking secondary to muscle spasticity. However, it is critical to determine whether a component of the toe walking is caused by spastic flexion of the knee and possibly also of the hip. Is the ankle truly in equinus or is the patient bearing weight on the forefoot because the knee is flexed? If the latter is true, heel cord lengthening results in a progressive crouch gait with worsened overall function and should therefore be avoided. Such a patient may benefit from a lengthening the hamstrings and possibly the hip flexors, not the gastrocnemius. However, management of complex spastic gait is beyond the scope of this article.
Patients with hemiplegic spasticity involving one lower extremity usually have true equinus. If the patient walks with the knee no more than slightly flexed and the ankle is in definite plantarflexion, the heel cord can safely be lengthened. If the ankle can be brought passively to neutral with the knee flexed, but falls into equinus as the knee is extended, the gastrocnemius insertion alone should be addressed. The gastrocnemius aponeurosis can be lengthened just before it joins the aponeurosis of the soleus (Vulpius or Baker) or the gastrocnemius to Achilles muscle-tendon junction can be lengthened selectively (Strayer procedure). If the ankle remains in significant equinus despite knee flexion, the Achilles tendon itself is lengthened through either an open or percutaneous technique, as described.
Heel cord lengthening can be considered in a patient with paralytic muscle disease who walks on the toes, but only if the knee extends fully and the quadriceps muscle has normal or near-normal strength. If the patient is using toe walking to generate an extension moment at the knee to compensate for a weak quadriceps, lengthening the heel cord causes a premature loss of ambulation. All patients with Duchenne muscular dystrophy during their last few years of ambulation use toe walking to compensate for weak knee extensors. Management of toe walking in such patients should be limited to nonoperative modalities such as bracing.
After a heel cord is surgically lengthened, the patient is typically immobilized in a below-the-knee cast for approximately 4-6 weeks. The position of the ankle is thought to be critical if a percutaneous approach was used, as the ankle is placed into more dorsiflexion if more lengthening is desired and less dorsiflexion if less lengthening is desired.
Adequate pain control in the acute postoperative setting is imperative both to promote the child’s comfort and to reduce muscle spasms, which may alter the desired surgical correction. The limb(s) should be elevated for 2-3 days until acute swelling resolves. Weightbearing on the limb is routinely permitted if a percutaneous or open sliding tendon lengthening was performed. For patients with open Z-lengthening, some surgeons prefer non-weightbearing until tendon healing is sufficient (approximately 6 wk).
The patient may resume walking on the operated limb once the cast has been removed. A patient with idiopathic toe walking (ITW) manifests a plantarflexion weakness out of the cast and runs flatfooted. The gastrocnemius-soleus complex typically regains strength slowly over the subsequent few months, returning to normal within 1 year. The patient is usually followed for 1-2 years after the surgical intervention to ensure that toe walking does not recur.
Immature patients with spasticity or paralytic muscle disease should be monitored closely after heel cord lengthening. With growth or continued muscle fibrosis, contractures are prone to recurrence. In these patients, stretching and/or orthotics are typically needed during growth to maintain foot position and prevent recurrence.
For excellent patient education resources, see eMedicineHealth's patient education article Cast Care.
The chief concern following operative heel cord lengthening for a patient with idiopathic toe walking (ITW) is recurrence. Although recurrence in ITW after surgery is uncommon, the authors have used molded ankle-foot orthoses (AFOs) for up to a year to manage recurrence before considering repeat operative lengthening. The diagnostic workup should be revisited for any patient with recurrent ITW after surgery as a means of looking for signs of neuromuscular disease or intraspinal pathology that might not have initially been evident.
Recurrence following operative heel cord lengthening is common in neuromuscular diseases, owing to continued spasticity and extremity growth. The appropriate use of an orthosis and stretching can help prevent this complication. A feared postoperative complication for patients with toe walking secondary to spasticity or paralytic muscle disease is deterioration of independent ambulation. Such complications are minimized by a careful preoperative evaluation and judicious selection as well as execution of a heel cord procedure. If function is adversely impacted by tendon lengthening, the foot and ankle should be supported with an orthosis.
Lastly, wound dehiscence, necrosis, and cutaneous nerve injury are relatively rare complications.
Outcome and Prognosis
The long-term results of treatment for idiopathic toe walking (ITW) is unclear as most studies mix a variety of management methods, making it difficult to critically evaluate individual treatment options.
Stretching casts have a variable reported outcome. In a long-term study of 14 children with ITW treated with a stretching regimen with or without casting, only 3 children required additional treatment for persistent toe walking after several years. However, in a larger series of patients, no difference was seen in outcome between patients treated with observation or serial casting, with 50% of both groups showing improvement in gait. Other authors have demonstrated similar variability, with one study showing that 66% of patients have improved ankle dorsiflexion and gait following casting.[20, 30, 37] Casting management overall seems to be most successful in patients with an initial ankle dorsiflexion of greater than 0º. In addition, recurrence of toe walking is unlikely in patients who have spontaneously discontinued toe walking or who remain down on their heels for more than 1 year following casting treatment.
Surgical management of ITW, either through isolated gastrocnemius lengthening or Achilles lengthening, appears to be effective when used in the appropriate clinical setting. In one study, 72% of surgically treated patients reported a normal or improved gait at follow up. Another study noted all patients treated surgically showed an improvement in ankle dorsiflexion and parental satisfaction was reported to be 67%. In long-term outcome studies, surgical management seems to be more effective than nonsurgical management. However, direct comparison is difficult, owing to the variability in patient age and disease severity in these studies.
The prognosis for patients with spasticity or paralytic muscle disease is less predictable. These patients require long-term follow-up, as recurrence rates are high. For ambulatory cerebral palsy patients without a fixed ankle contracture, treatment with full-time bracing (ankle-foot orthoses [AFOs]) has been shown to have a positive effect on ankle range of motion and power at push-off.
For cerebral palsy patients with a rigid deformity, data indicate that children younger than 7 years at the time of surgery have a higher risk of recurrence. Hemiplegic patients have also been found to have higher recurrence rates compared with diplegic cerebral palsy patients. In one long-term study, surgical lengthening in cerebral palsy patients with a fixed equinus contracture resulted in a significant gain in dorsiflexion from a preoperative average of -25° to 8° of dorsiflexion postoperatively, and this correction was shown to be maintained by stretching and AFOs in 80% of patients 7 years after the index procedure.
Botulinum toxin alone has not been shown in randomized control trials to offer improved outcomes over the long term when compared with casting alone for dynamic equinus in children with cerebral palsy or ITW.[33, 41] Furthermore, combining botulinum toxin injections with casting does not improve the results for either patients cerebral palsy CP or ITW compared with casting alone.[33, 41]
Future and Controversies
Some controversies exist regarding the widespread use of electromyography (EMG) and gait analysis in diagnosis. However, both analyses may be helpful in select patients. (see Other Tests).
An auditory feedback system to assist in gait rehabilitation of cerebral palsy patients with dynamic toe walking has recently been developed. Based on plantar pressure monitors embedded in shoes, this system can monitor toe-walking strides in real time and produce an auditory signal to alert patients when toe walking has been detected. Although this system was designed to identify toe-walking strides in children with cerebral palsy, its use may also be expanded in the future to provide a behavior-modifying feedback system for children with idiopathic toe walking (ITW).
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