Occupational therapy and habit re-training for idiopathic toe walking

I don't know that I have ever seen any occupational therapy literature on idiopathic toe walking.
For an excellent overview and references on this condition please check this article from the Journal of Family Practice.

As the reference states, it is important to avoid 'over medicalizing' the problem especially since there are not many toe-walking adults that are presenting themselves for intervention. It is possible that toe walking is a self limiting problem in many children. However, there is a reasonable concern when toe walking begins to contribute to pes cavus deformities which of course can have longer term implications. In our clinic we see a few children each year with toe walking that is beginning to cause functional foot deformity.

Idiopathic toe walking is a relatively common condition that is often seen by occupational therapists - but not generally as a primary reason for referral. Some professionals view toe walking as a marker of other developmental immaturities. It is critical to make distinctions between true idiopathic toe walking as opposed to toe walking associated with cerebral palsy, autism, muscular dystrophy, or other conditions. Toe walking should always be evaluated by a medical diagnostician first to rule out these other more severe conditions.

Some occupational therapists attribute toe walking to sensory problems but there is no evidence that this is true. Many occupational therapists leave intervention for toe walking to physical therapy colleagues who are often more specialized in nuances of gait analysis and biomechanics of ambulation. However, I have found that traditional physical therapy interventions often fail to address some of the specific problems associated with idiopathic toe walking.

There is a lot of literature that discusses different treatment options including serial casting, range of motion, and strengthening. Medical interventions often include botox injections or muscle lengthening. There is debate over which of these are most effective, or if they are at all effective.

At our clinic we try to complement traditional biomechanical interventions with re-training for self care (dressing) habits. Many of these children do not like to wear shoes and as soon as they come home from school the shoes are off and the children are tiptoeing around the house and yard barefoot. Toe walking without shoes promotes hyperextension of the toes and exacerbates the muscle imbalances that are already occurring in the foot and lower leg. Even when parents know that allowing their children to be barefoot can exacerbate the problem - it is difficult for them to effect behavioral change.

When there is no orthopedic or neurological cause of the toe walking we add a positive reinforcement component to the intervention program. The goal of this is to promote shoe wearing throughout the day and to break the habit of being barefoot. We find that children respond well to a 'puzzle' that has bones of the foot, and they can 'earn' puzzle pieces each day for successfully keeping their shoes on for a specified duration of time. Each day that they wear their shoes they get a new piece to add to the puzzle.

After the children complete the puzzle by earning all of their foot bones they are able to win a specified reward. Children respond well to the visual cue of the puzzle, are easily able to understand their progress toward the goal of wearing shoes every day, and like to learn about the way their feet work. Parents also benefit from use of the bone puzzle because it is easy to implement and is also helpful as an educational aid for teaching them about biomechanics of the foot.

If shoes fit properly and are supportive it is difficult to toewalk. Thankfully, Converse Chuck Taylors are back in style with kids! We find that compliance with regular shoe wearing is improved with use of 'cool' sneakers and the prospect of earning a reward by completing their puzzles.

It is important to have good dialogue with the orthopedic doctor and orthotist. Depending on the degree of functional foot deformity sometimes it is necessary to have even more modification to shoes including SMOs, AFOs, or modified shoes with a high toe box to avoid pressure sores.

We don't see enough children with idiopathic toe walking in our clinic to do a well designed study but still have had good anecdotal success with our combined biomechanical intervention and behavioral program. It would be interesting to see if the behavioral component increases the length of time that children demonstrate more functional gait patterns following intervention.


Reference:

M. Patrice Eiff. "What is the appropriate evaluation and treatment of children who are "toe walkers"?". Journal of Family Practice. . FindArticles.com. 17 Sep. 2008. http://findarticles.com/p/articles/mi_m0689/is_5_55/ai_n26877929

Comments

Anonymous said…
i think i may have this disorder. i have been walking on my toes since i was a young girl. i am 35 now and i still walk on my toes when my shoes are off.my question is would this cause problems for me now. i have hyperflexing in my legs when i flex them they shake could this be due to my toe walking or an underlying condition of the nervous system? thanks april
Chris said…
Hi April -

It is important to talk to your doctor about these kinds of concerns. As I posted, there are many reasons for toe walking and by talking to your doctor you can start along the 'path' to finding out if you need to do anything about your concerns.

Thanks for reading!

Chris
Anonymous said…
Hi there,

I came across your blog, because I was looking for doctors who specialize in treating toe walkers. My son is almost 6 years old, and has been toe walking since he was about 3. We have done physical therapy, he wears braces at night, we've tried high tops, but nothing seems to work. Our doctor has mentioned serial casting as well as surgery, but as you said there is no 100% guarantee that those will work. Where is your practice located? What brands of sneakers/shoes do you recommend to your patients? Thanks so much, it's so frustrating not being able to help our son.
Chris said…
Hi Anonymous..

Our office is located near Buffalo, NY. Our website is www.abctherapeutics.com

As I wrote, toe walking may be due to a number of factors, so it is not possible to give a definitive answer to your questions without knowing a lot more about your child and what would be most appropriate in his situation.

You should discuss your concerns with his medical doctor and get more information on the options that have already been proposed. If you are convinced that conservative intervention just won't be successful then you need to educate yourself on other medical options.

If you are dissatisfied with your current therapy options and are not ready for medical interventions, and if you have not done so already, I encourage you to make an appointment with a knowledgeable pediatric OT or PT who has a lot of experience dealing with this issue. They will do a full evaluation and work with your MD to help you develop some revised intervention strategies.

Best wishes,
Dr. Chris
Vivi said…
My goodness, I have been toe walking my entire life. I am now 50. I find high heels to be the most comfortable shoes for me. My legs and back hurt horribly if I wear flats. Luckily, I love heels.
When I am barefoot, I am always on my toes. My heel never hits the ground. I knew I walked differently than others, but I never realized it was a real problem. It is interesting to learn something new about one's self! Thank you for your blog.
Anonymous said…
well i am 38, have tried tendon lengthing operation, serail casting many times but have to have it cut off as my toes go blue and the pain is a killer, 6 weeks with no sleep is hard.
and was thinking to try botox next but no cure yet.
maybe i never will....
Anonymous said…
I am 70 and have walked on my toes all my life....so what?
sue
Chris said…
I love the comment from the anonymous 70 year old! LOL that made my day. It is a testament to the adaptability of the human body that all those years of walking in a 'different' way did not cause you difficulty. I am glad that it did not!

Some people do have ill effects, and for those people there are things we can try to help.

Thanks for reading!
Anonymous said…
I am 52 and walked on toes all my life. But now neuromas, cysts, plantar faciitis and achillis heel absolutely own me with pain. Im wishing I would have looked seriously into toe walking before any damage was done. My dad used to call me twinkle toes and we just thought it was funny. Not so funny anymore. Owwww

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