Intoe gait (pigeon toed) is a common childhood problem. It is estimated to occur in 10% of children between ages of 2-5 years. In most cases this is an entirely benign condition and is a feature of normal variation of growth pattern.
Lack of any symptoms such as pain, symmetrical deformities, absence of any stiffness in the affected joints and no associated systemic disorders or syndromes indicates a benign condition with excellent long-term outcome.
Most children with this deformity spontaneously stop intoeing before the age of 9 years. No treatment is therefore required in the majority of cases.
There are 3 main causes of intoe gait:
• Persistent femoral anteversion
• Internal tibial torsion
• Forefoot adductus
Persistent Femoral Anteversion (PFA). PFA is excessive anterior twist within the upper femur. Normally in adults the upper femur is anteriorly rotated in relation to the lower femur (femoral condyles) by 15°. In young children this angle is about 30°, but this steadily reduces to adult angles by the onset of adolescent growth spurt.
On examination of the hips in children with PFA, the most striking feature is excessive range of internal rotation, but limited external rotation.
As previously mentioned in most cases this is an entirely benign condition and requires no treatment.
Internal Tibial Torsion (ITT). Tibia is normally rotated externally in relation to the femur by 20°. This is best measured by comparing the intermalleolar axis to the intercondylar axis. Another simple way of assessing this relationship is to measure the thigh-foot angle with the child in prone position and knees flexed to 90°.
In ITT the tibia is found to be internally by more than 10°-20°. This phenomenon is extremely common at birth and rapidly remodels to normal levels within the first few years of life. However, in a minority of cases ITT may persist until onset of adolescent growth spurt. This condition is unlikely to persist into adult life and rarely creates problems severe enough to require treatment or correction.
Forefoot Adductus is another important cause of intoe gait. In this condition the foot has a curved lateral border rather than being straight. The forefoot therefore appears to be turned in. This condition could easily be distinguished from club foot as there are no fixed deformities within the hind foot.
This condition has a tendency for spontaneous correction with age. Long-term prognosis is usually very good and treatment is not required in most cases.
For severe cases, especially when it is unilateral, application of serial corrective casts could be very effective. Surgical correction is rarely needed .
While commonly used as a children’s slang, and not technically, it is simpler and faster to say ‘on tippy toes’ than “on the balls of the feet” (as the latter takes longer, and some are not aware of the meaning). Furthermore, it has use as a verb, “to tip-toe“, which is also simpler than “to walk on the balls of the feet”.
Causes of Intoe Gait
Internal Tibial Rotation
Thigh Foot Angle
To go into tippy toes, the ankle must be flexed to raise the heel off the ground. This requires the engagement of the calf muscle, along with various other muscles in the foot and shin to stabilize the joint. Even with this, this form is often less stable, requiring the engaging of muscles within the torso and a better sense of weight for the person, to stay balanced. There is generally some movement, even subtle, in the ankle, as holding it statically would make balance difficult, so it is the first to give.
Raising up on the toes will increase someone’s height and reach. It is used often to make someone appear taller, whether in an engagement, or when measuring one’s height. It is also used to reach objects that are higher up than one cannot reach when on one’s heels.
Walking only on the balls of the foot greatly reduces the surface area of the foot on the ground, allowing what does touch the ground to be more carefully placed, which is useful for avoiding twigs. The disadvantage is that it will also focus the weight, which leaves greater indentations and exerts more pressure. This will commonly happen in walking, but can be slowly controlled, so it is more a factor for when wearing shoes in the dark (or when one has one’s eyes or attention averted elsewhere), when obstructions cannot be felt with bare feet, or seen.
Moving quickly on tip toes is generally quieter, as the calf muscle can absorb much of the impact. The heel directly striking the ground is quite noisy, and often painful in bare unconditioned feet. Many[who?] believe that running heel-toe is quite unnatural and that our build is more accommodating to tip toe running.
Prowling about on tippy-toes is the stereotypical candor of a thief or spy, often accompanied by light tones sounding upon each of his or her steps.
When rotating on either one leg or two, the body requires reducing friction. Raising to one leg is often one source of doing this, although since it doubles the weight on the other leg, it is not effective, so is mainly done when the other leg is used to torque to increase a spin, or very quickly so that the mass is more in the air, and has not settled on the other foot.
The main method of decreasing the friction, is decreasing the surface area of the foot. This is done by either going on the heel of the foot, ball of the foot, or sometimes, the toe/toes of the feet (often only possible by very light people, such as Rose in Titanic, or those with ballet shoes for En pointe known as pointe shoes, or ice skates).
The reduction of surface area is not actually what decreases the friction, however. Rather, the weight of the body is centred above the point of contact, so that the centre of gravity occurs on the axis of rotation. This allows a faster spin with far less force placed upon the stabilizers. Bringing in the limbs (much like on a spinning swing) also accelerates this.
With two legs, the centre of gravity would still occur on the axis of rotation, and be centred directly between the two points of contact.
The friction of rotation is still considerable, however, and tends to wear, toughen, and polish the area of the foot being rotated upon. As a comparison, in breakdancing, those who perform headspins often go bald. The foot is more tailored to absorbing and benefitting from such rotations, although perhaps not so much on hard level surfaces, as our natural environment usually is uneven and has some give. This is why it is easier and safer to do by implementing one of two factors:
- Reducing friction by doing it on a polished slippery floor, or ice, or wearing footwear which has less friction or is more able to absorb it, such as a sock, ballet shoe, or skate.
- Increasing give (and possibly friction) but spreading the force to a larger area of the foot by having give, mostly in the surface (such as gym or karate mats).
Rotating on the ball of the foot is normally preferred due to the normal advantage of tippy toe, and the springyness of the body, which is why many martial arts encourage sparring opponents to stay on tip toe the entire match, for better movement as well as rotation. As there are actually two surfaces to the ball of the foot, and toes to grip, it also allows better control.
In theory, however, rotation on the ball of the foot is actually much faster. The main problem being, the danger of either falling backwards, or of not keeping up the pose, falling back on the balls of the foot. Twists done on the heel of the foot are often quick twists, done leaning backwards while bringing the foot upwards in an arc, so that it is more of a controlled fall that the other foot can come out and stabilize.
Walking on Tip Toes 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 tip 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 (calf muscle). The patient who has a severe achilles tendonitis (pain in the back of the calf muscle) or severs calcaneal apophysitis (heel pain) might tip toe to take some of the tension off of their achilles tendon. A rarer cause of a child tip toeing on one side only could be deep muscular calf hemangioma, this is a vascular neoplasm which causes swelling of the calf muscle.
Walking on Both Tip Toes
The most cause common is idiopathic toe walking (no known cause), also called habitual toe walking. Walking on tiptoes is quite common between 10 and 18 months when children are learning to walk. In some children it simply becomes a habit, when asked to walk normally they put their heel down on the ground before their toes. It’s just that when they’re not concentrating they seem to revert to walking on their toes.
Mild spastic diplegic cerebral palsy is also very common. Then more rarer conditions that can cause children on walking on both tip toes are 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.
Early onset tip toeing is defined as tip toeing that occurs within three months of the the child walking. Far and away the two most common reasons for this are idiopathic toe walking and spastic diplegic cerebral palsy. Cerebral palsy refers to a group of conditions that affect control of movement and posture. Because of damage to one or more parts of the brain that control movement, an affected child cannot move his or her muscles normally. While symptoms range from mild to severe, the condition does not get worse as the child gets older. With treatment, most children can significantly improve their abilities.
Late onset tip-toe gait is defined as tip toeing which begins at least about four months after a patient has had a well-developed normal heel-toe walk. This is virtually always due to some neuromuscular problem which will require an examination by a neurologist.
It is also important to note if their was a family incidence of tip toe walking. One of the most common contributing factors is a tight achilles tendon. Normally, a child should have about 10 degrees of ankle dorsiflexion (the amount your foot can extend towards your body when the foot is not tensed); however, a child can walk with a normal heel-toe gait as long as they can get to this neutral (The sub taler joint in the ankle is neutral when it is neither twisted in nor twisted out.).
Most children will need to be referred to a physiotherapist, orthopedist and neurologist for treatment.
Idiopathic toe walking may be cured by just observing the condition and hoping that the child might eventually outgrow their tip toe gait. If you want to control an overactive calf muscle then the doctors might try to just hold it still with an ankle-foot orthosis (AFO Brace). If it is being caused by a tight achilles tendon then surgery may be required. The most common procedure is a gastrocnemius recession procedure. An alternative could be casting to correct the achilles tendon.
It can be very difficult to distinguish between idiopathic toe walking and mild spastic diplegic cerebral palsy. It seems simple enough, but it really is not because both conditions are highly associated with premature birth, developmental delay and tight achilles tendons. However a good sign is if the child can walk completely normal when you ask them to, it is more likely that they might have idiopathic toe walking.
For psychiatric toe walking, there is just no literature about how to treat this. There is very little literature about it at all. It’s seen once in a while in schizophrenic children, autistic children or children with learning disorders. There are no relevant treatment option that have been documented for this.
Spastic diplegic cerebral palsy is again almost always early onset tip toeing. The family history is negative and they should have upper motor neuron lesions or dynamic EMG (Electromyography is a test that assesses the health of the muscles and the nerves controlling the muscles) that is abnormal. If their is an over active achilles tendon then you could use bracing. If a patient’s dynamic contracture is so strong that they are fighting the brace, and then the doctors might try casting or Botox (Botox is an experimental treatment) to weaken the muscle and then continue with the brace. If the achilles is physically tight, then a lengthening procedure would be used and perhaps a hamstring lengthening also if the patient is crouching significantly.
Signs of upper motor neuron lesions include weakness, hyperreflexia (Reaction of the autonomic (involuntary) nervous system to over-stimulation), and increased tone. Note that with acute upper motor neuron lesions there is often flaccid paralysis (weakness or loss of muscle tone resulting from injury or disease of the nerves innervating the muscles) with decreased tone and decreased reflexes.
Around the time children start to learn to walk, around 9 to 16 months old, they are often unsteady, have a wide base of support, and they may sometimes prefer to walk on their tiptoes. Studies have shown that toe-walking is considered an acceptable part in normal development. Toe walking is common up to 18 months, but may persist until the child is 2-3 years old. The child usually grows out of toe walking and develops a heel-toe gait pattern at the age of 3.
Persistent toe walking, beyond 3 years of age, may be associated with diagnoses such as cerebral palsy, autism, spina bifida, tethered cord syndrome, muscular dystrophy, sensory integration deficits, or other neuromuscular issues. Other cases of toe walking may have no known etiology, and is diagnosed as Idiopathic Toe Walking. In any of the cases, children may benefit from interventions such as physical therapy, footwear modifications (shoe inserts, heel lifts), ankle foot orthotics (AFO), serial casting. Although it is rare, surgical intervention may be an option to lengthen tight heel cords that may be causing the gait abnormality.
Physical therapy intervention usually involves passive and active range of motion exercises that focus on the ankle stretching (usually tight calf heel cords), strengthening, gait training, balance training, and a home exercise program. In addition, a physical therapist is also involved in suggesting if/when other interventions, such as footwear modifications and orthotics, are appropriate.
Most children will eventually outgrow their tip toe gait but if you have any doubts then you should visit your family doctor as the first point of call.
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