Up On Our Tippy Toes (Part 1)

Posted on October 26th, 2013 by Denise | No Comments

Up On Our Tippy Toes (Part 1)

By

Denise Koonce OTR

October is the month we celebrate the profession of physical therapy and all that it has contributed.   The American Physical Therapy Association deemed this year’s theme “Move Forward PT”.  Physical therapy has had a vital role over the last century in caring for those in need of reconstruction or rehabilitation.  They began by rehabilitating the wounded soldiers from WW I, WW II, the thousands adversely affected by the polio epidemic, and then along with the Hill Burton Act, began treating in the general hospital population.  From the general hospital population, the profession continued to “Move Forward” in several directions and now provides care in a multitude of situations and populations.  Over the decades their foundational roots in modalities, massage, and movement have remained but not necessarily stayed the same, as they are always seeking avenues to move forward.  Despite their immense diversity and wide expanse of treatment approaches one primary area stands out, gait.  It is not gait as a whole that I wish to address but one very small portion of it; toe walking. 

This past weekend I had an opportunity to be around about 200 children from the ages of 5 to 14.  During that time period, I was able to observe them moving about from place to place and from one gross motor activity to another.  While doing so I noticed a handful of kids who were walking on their toes.  It is at that moment that the mommy hat goes off and the therapist hat comes on. There is something that occurs with therapists, I believe, which comes honestly, automatically and instinctively.  Therapists are continually assessing individuals around them through observation, without even realizing it.  I have caught myself doing this in the airport, grocery store, my daughter’s school, the park, really anywhere there is a large group of people.  Most areas that I pick up on, when observing children, have probably already been addressed either through their parent, pediatrician, or school.  However, there are a couple of areas that make me cringe when I see them exhibited in older kids.  The areas I am referring to are in-toe, out-toe, and toe walkers.   I cringe when I see individuals with these gait patterns because many times if those patterns would have been addressed early on, their gait would be more normal and therefore less problematic.   There has been so many instances when speaking with friends, family and even patient’s family regarding these diagnoses, that the response from the medical world was “Don’t worry, they will grow out of it.”  Unfortunately, that isn’t always the case.

Toe walking can occur for three main reasons.  These reasons are sensory related dysfunction, an underlying diagnosis such as muscular dystrophy or cerebral palsy, and the third reason is unknown or idiopathic.  The first reason, sensory related, can be from a hypersensitivity to the soles of their feet creating a painful response.  Due to the painful response, they walk on their toes to minimize contact with the surface.  Also sensory related, but opposite from sensory defensive is sensory seeking.  This individual will walk on their toes to increase the proprioceptive input received when they lock their ankle and knee joints during gait.  This occurs when they are attempting to stabilize their body in space and is sometimes demonstrated in individuals on the sensory/autism spectrum.  

The second reason for toe walking is an underlying diagnosis such as muscular dystrophy or cerebral palsy.  Muscular dystrophy is a genetic disorder which causes the muscle tissue to be destroyed.  One of the first noticeable signs this is happening, in a child with muscular dystrophy, is when the child begins to have difficulty walking and attempts to stabilize themselves by toe walking.  The other underlying diagnosis is Cerebral Palsy which is neurologically based and affects muscle tone.  The abnormal muscle tone can affect the child’s movement significantly or in this case minimally, causing toe walking.

The third reason is unknown or idiopathic and therefore we do not know why the individual chooses to walk on their toes.  These individuals do not have a sensory issue or an underlying genetic or neurological deficit producing the toe walking.  These are the individuals, in my opinion, that tend to fall through the cracks and do not receive proper intervention.  Without intervention, the individual will continue the irregular gait pattern allowing the calf muscles to shorten therefore creating a vicious cycle.  That cycle will then make it more difficult for the individual to stop the habit of toe walking.             

Please join me next week as I continue the discussion on toe walking.  In the meantime, reach out and tell your physical therapist or a physical therapist you know,  “Happy PT Month” and thank them for all that they do.  Keep “Moving Forward PT!”

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