Evaluation and Treatment of the Child with Tiptoe Gait
Narulita Dewi MD
PHYSICAL MEDICINE AND REHABILITATION FACULTY OF MEDICINE INDONESIA UNIVERSITY DR CIPTOMANGUNKUSUMO HOSPITAL JAKARTA INDONESIA
· This is what we will be talking about. This is the toddler, the 3 Year-old who walks into your clinic waiting room walking on tip-toes. Here in the Miami we cannot blame that on a cold floor. Mom gives a history that the child walked at the normal time, but has always walked on tippy-toes. It was cute in the beginning but now the child is getting ready to go to preschool and mom is a little concerned that he might get teased.
· What should be done about that? The first thing we need to do is figure out if it is normal. Can it be normal to walk on tippy-toes? Surprisingly enough, there were a couple of researchers and one of them, found that there is a brief period of time where children may tip-toe intermittently, and it would be considered normal for that brief period of time right when children first start to walk up until maybe just after 2 years of age. After that, it is no longer considered normal to walk on tip-toes bilaterally.
Normal Heel-Toe Gait
· As you can see here, a normal gait is called a heel-toe gait and that means that as one leg swings forward, it lands with the heel on the ground first.
· Then the body proceeds over that stance phase limb and finally the foot raises up on tip-toe right before it swings forward again. As you can see, when the leg is on tip-toe, the other leg is on heel strike so in normal gait there is never a time when a child should be on tippy-toes bilaterally.
Unilateral Tiptoe Gait
· Unilateral tip-toe gait but only have 30 minutes so just mention that there are some common reasons for a child to walk on tip-toe just on one side. One of the more common reasons is that one leg is quite short and if the leg is more than about 3 cm short, a child will often compensate by tippy-toeing so that the leg reaches the ground. A child that is spastic in one leg or one side of the body may tend to tip-toe on that side because of the overactive gastrocnemeus. The patient who has a really rip-roaring Achilles tendonitis or Severs calcanea epiphysitis might tip-toe to take some of the tension off of their Achilles tendon.
· In the business long enough that I have actually seen the bottom three and they are all considered quite rare causes of unilateral tip-toeing. Deep muscular calf hemangioma can cause it. Morphia or linear scleroderma behind the ankle can cause a soft tissue contracture with an equinous deformity. I even had one patient. I have to tell you this story. It was a teenage girl who just moved to Miami from Colombia. Two years before, her leg had been lightly trampled at a rock concert and ever since that event she walked on tip-toes.
· A lot of information about the initial injury but basically when examined her, her foot was in maximum equinous. I could not push it up at all and of course being a surgeon, recommended surgery to fix that.
· The operating room and as soon as the anesthesiologist put her to sleep, she had perfect ankle motion. A tight Achilles tendon at all and was completely fooled by psychological conversion reaction which is what we finally figured out was going on.
Bilateral Tiptoe Gait
· Bilateral tip-toe gait and this is a menu of things which should go through your mind when child walking on tip-toe bilaterally.
· The more common ones are idiopathic toe walking, also called habitual toe walking. Mild spastic diplegic cerebral palsy is also very common. Then things get less common as you go down the list. There are things that should not be forgotten like Charcot-Marie-Tooth peripheral neuropathy or muscular dystrophy, such as Duchene. Then, even some less common things like autism, schizophrenia and finally spinal cord anomalies and juvenile type multiple sclerosiS
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