12/12/2013    Ron Raducanu, DPM

2 1/2 Year Old Toe Walker

Her lack of speech can be significant. Is she
seeing a speech therapist for this and what is the
origin of this pathology? When you say
"neurologically intact", does that mean no clonus?
It also sounds like the "deformity" is flexible.
Is there any rigidity to the midfoot/rearfoot at
all? Have the parents agreed to an x-ray? If so,
what were the findings? I like to check an x-ray
if the parents agree, and if there is even a hint
of rigidity.

When she walks initially, what is her cadence?
Does she start off slowly and then pick up speed
when she starts to toe walk? Does she heel strike
when she runs or does she only toe walk when she
is walking after a few steps? If you ask her to
walk very slowly, does she still toe walk or if
you tell her to put her heels down, can and will
she? When she walks does her gait look "normal" to
you other than the toe walking. No excessive sway,
shoulder tilt, back mal-alignment? When you
watched her walk, was she barefoot and wearing
shorts so you can really get a good look at her
hips, legs and feet?

Sorry for all the questions, but if she can avoid
toe walking at times and doesn't toe walk in
certain situations, it is likely something that is
ideopathic. In my experience I've found giving the
feet another proprioceptive stimulus can help to
dissipate the problem. Something benign like a
Gibney Boot (with an emphasis on splinting the
ankle to not allow excessive contraction of the
Achilles) could test for this and if it is
successful in stemming the issue, potential
consider a good OTC orthotic to continue that
stimulus and eventually wean the patient out of it
as the issue begins to go away. The other thing to
try is a very light OTC MAFO while the patient
sleeps as it is unlikely that an active 2 year old
will willingly wear something like that throughout
the day, while playing.

My other thoughts are to consider if there is a
family history of connective tissue disease as the
musculature can try to compensate for a midfoot
collapse this way. At this age it would be hard to
know for sure, but if the child is overly
flexible, this is something to potentially
consider.

Many times with this, I talk to the parents about
working with a pediatric occupational therapist to
give parents tricks on how to coax their child
into realizing they are on their toes and getting
the child to self correct (if possible). This has
worked wonders and parents are grateful as this is
a non-invasive method of helping their child.

Ron Raducanu, DPM, Philadelphia, PA,
kidsfeet@gmail.com

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