A multidisciplinary approach offered benefits for a pediatric patient who had idiopathic toe walking with severe contractures, according to Nicole M. Harris, PT, PCS, BOCO, of The Children’s Hospital Colorado in Aurora, Colo. Harris presented the case study at the Association of Children’s Prosthetic-Orthotic Clinics Annual Meeting, in Broomfield CO.
by Amanda Alexander, Healio O&P News April 16, 2016
The kindergarten-age patient was referred to Harris for physical therapy from the hospital’s orthopedic department to gain dorsiflexion (DF) range of motion (ROM). The patient presented with DF ROM of -40° bilaterally and could only walk on his toes. He was unable to stand flat-footed or stand still without stepping to adjust his balance.
Harris said the patient’s intervention plan included bilateral ankle foot orthoses (AFOs) with adjustable joints to allow for adjustment of the DF angle during a series of months. The patient’s shoes also were modified with a 35° heel wedge to accommodate contracture, allow weight-bearing in the heel and provide normalized biomechanics. In addition, the AFO joint was set with a plantarflexion block and slight resistance to DF to support the patient’s tibia and encourage forward translation over the stable foot to develop plantarflexion strength and control.
The patient was assessed every other week by a physical therapist and orthotist. The orthotist adjusted the wedges every 2 weeks to 4 weeks, decreasing the wedge by 5° to 10° and increasing the DF angle.
During AFO use in the first 6 months, the patient reported increased stability and demonstrated he could run, stand on one foot and skip. Frequent falls were eliminated, and the patient showed increased function. The patient’s ROM increased to -15° on the right and -25° on the left.
After the patient’s DF ROM plateaued, serial casting was used for 7 weeks. The casts were changed weekly and heel wedge use continued.
The DF ROM subsequently improved to 0° on the right and -3° on the left. The patient also transitioned to carbon fiber, posterior leaf spring AFOs. Physical therapy continued every other week, and the patient transitioned out of AFOs to supramalleolar orthoses. He was able to walk heel to toe with and without orthoses, and could run and jump after the second round of casting.
At 3 months after casting was completed, the patient showed a slight loss in ROM to -5° bilateral due to a major injury that occurred at school. He underwent a Strayer procedure and needed continued foot orthoses, night splints and physical therapy.
Source Healio O&P News
Multi-Disciplinary Approach: Treatment Of Idiopathic Toe Walking With Severe Contracture, Harris N, et al. Challenging case #1. Presented at: Association of Children’s Prosthetic-Orthotic Clinics Annual Meeting; April 13-16, 2016; Broomfield, Colo.
Idiopathic toe-walking in children, adolescents and young adults: a matter of local or generalised stiffness? Raoul Engelbert, Jan Willem Gorter, Cuno Uiterwaal, Elise van de Putte, and Paul Helders, BMC Musculoskelet Disord. 2011; 12: 61. Published online 2011 Mar 21. doi: 10.1186/1471-2474-12-61
A comparison of orthoses in the treatment of idiopathic toe walking: A randomized controlled trial, Herrin K, Geil M. Prosthet Orthot Int. 2016 Apr;40(2):262-9. doi: 10.1177/0309364614564023. Epub 2015 Jan 27.
Two Boys with Idiopathic Toe Walking Treated with Different AFO Design, Jenny McEwen-Hill, Don Weber. ACPOC News 2009 Vol 15, Num 1 > pp. 5-16
Why is my Child a Toe Walker? in Jones Therapy Services