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, email@example.com
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