Tiptoe in the child - Christina Cherry

introduction

The tiptoe becomes about 5% of the children observed in preschool age.

The term tiptoe is actually not quite right, because the kids on the forefoot run, the Toes flat on the floor lie and the rolling process largely absent. So the term would be more appropriate toe walking.

Children with such a gait pattern are more common in Orthopedists presented. If a toe duct has been in existence for more than three months, it is classified as "Persistent" (persistent) designated.

causes

Idiopathic tiptoe

In many children, intensive diagnosis and questioning will not cause the Toe transition clear.

So there is no underlying physical or mental illness, the tiptoe occurs for unknown reasons. One speaks here of idiopathic (unknown cause) or habitual Toe walking. The habitual toe tip can in 3 shapesn can be divided.

Type I

Type I makes up about 1/3 of the cases, the gait anomaly has one muscle shortening as the cause. Most of the time, the children cannot go on the entire foot area stand and you balance is impaired.

Type II

For type II the tiptoe occurs in the family piled up, so there is one genetic component based. This type 2 occurs at something more than half of all idiopathic tiptoes. The children can then go all over foot surface standing and walking on normal heel when requested, but this must be done hip be rotated externally.

Type III

Type III is called "Situational tiptoe" designated. The children can walk on the heel without problems, only with burden (in certain situations) they involuntarily return to the tiptoe. The type III patients also fail in part difficulty concentrating and unusual behaviors on.

Many of these children develop during childhood without medical treatmenta perfectly normal gait. Especially with children who are about to To learn to walk, occurs frequently Toe walking which usually changes into a normal gait pattern after 3 to 6 months. It is important that the idiopathic tiptoe is always one diagnosis of exclusion is, that means that other diseases must first be excluded in order to be able to make this diagnosis.

Shortened Achilles tendon

When idiopathic or habitual toe walking is often Achilles tendon shortened. In addition, the Calf muscles contracted (tense). There is disagreement among medical professionals as to whether these two symptoms are the result or cause of the toe duct.

Neuromuscular causes

There are many neuromuscular diseases, where tip-toe walking may appear as a symptom, and the causative disorder can be found at all levels from the brain to the executing muscle.

Above all, the cerebrum, which is the command for the muscle contraction or to name the spinal cord that forwards the commands. The associated clinical pictures are e.g. a spastic cerebral palsy or a delayed maturation of the Corticospinal tract (A strand of the spinal cord). The distinction from the idiopathic tiptoe is often difficult.

With the idiopathic tiptoe, even with the knee bent, the foot is bent as if the child was standing on the toes. With spastic cerebral palsy, however, the foot comes on genuflection often in an extension position (tiptoe pointing towards the nose).

The delayed ripening The corticospinal tract occurs frequently in some families, here the tiptoe changes mostly into an age of 6 to 8 years normal gait pattern around.

Even with the progressive muscular dystrophy, an inherited muscle disorder, an increased sensitivity of the muscle fibers to tiptoe can occur. It is typical here that the children first enter normal gait pattern develop and only subsequently into one Toe walking pass over.

Furthermore, different nerve disorders lead to a tiptoe.

club foot

Clubfoot is one congenital malposition of the foot, which often occurs on both sides. Because of this misalignment, Toe walking come. Frequently learn the affected children run late and are noticeable due to unsafe walking.

Mental disability

Studies have shown that a Toe walking occurs much more frequently in mentally retarded children than in other children.

One guess is that these children have disturbed balance perception and the tiptoe helps them get more accurate information about the balance from the ankle.

Another theory says that the children in their Development lagged behind are and so initially on a stand of learning to walk have stopped where the heels Gang is not yet mastered.

autism

As autism it becomes congenital serious developmental disorder referred to, which concerns information transfer and processing.

Those affected fall through early in childhood lack of communication and social interaction skills on. In addition to stereotypical behavioral patterns and remarkably good skills in attention, intelligence and memory Coordination difficulties characteristic. So a tiptoe is at to the half of autistic children observed, adult autistic people, however, mostly no longer run tiptoe.

The affected children also move around, sometimes bouncing, whirling, or stalking. Researchers suspect that the children compensate for a vestibular (balance-related) disorder.

Conversely, the accumulated occurrence of the Toe Ganges in autistic children Not, that most of the children who occasionally walk on tiptoe are autistic. The habitual shape of the toe tip is far frequently and if none at the child behavioral problems observed, there is no reason to suspect that the child may be autistic.

There is a form of autism – Asperger syndrome. Asperger syndrome is characterized by difficult social interaction, like missing or reduced feeling of empathy and lack of understanding of emotional messages like friends, sadness, anger or anger.

Diagnosis

A tiptoe is often harmless and occurs only temporarily.

To be more serious neurological or mental To rule out the causes, the doctor decides on a case-by-case basis for a more or less complex diagnosis. This depends on the age at which the tiptoe occurs, how long it has been going on or what other symptoms have been noticed.

In any case, the doctor considers exactly that Gait of the child. He examines the anatomy of the foot, ankle and the calf. Hip and knee joint mobility should also be tested. It is also important to check the child’s sense of balance.

Gait analysis can also be done electronically by capturing reflectors done on the skin by many small cameras. An EMG (electromyogram) also measures muscle activity to rule out nerve or muscle disorders. In particular, the Fußhebermuskel (Anterior tibialis muscle) checked for its function.

If there is a suspicion of one cerebral palsy, If a mental disability or autism is the cause, appropriate neurological function tests are carried out and the mental development is checked.

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treatment

Treatment also depends on the cause of the tiptoe.

If the tiptoe exists due to another disease like one neuromuscular disorder, clubfoot or in the context of autism, this underlying cause should be treated as best as possible.

If causal therapy is possible, walking with the tiptoes will also become one normal gait pattern turn. The forms of therapy mentioned here mainly relate to the idiopathic Tiptoe and forms in which the underlying disease cannot be treated as the cause.

physical therapy

Are from tiptoe almost exclusively preschool children affected. In approximately 50% of the time, the problem of tiptoe walking up to the start of school takes care of itself. The physiotherapeutic approach first includes assessing the severity. For this, the feet and legs are examined. Particular attention is paid to the mobility of the upper and lower ankle, as well as the other large joints of the lower extremity such as the knees and hips. It is also important to observe the gait pattern closely and to evaluate it accordingly. Around one third of those affected develop one Shortening of the calf muscles or the Achilles tendon. By appropriate physiotherapeutic stretching exercises can this eliminates become. In addition, the physiological arch of the foot often flattens out and can be rebuilt using physiotherapy.

The children also tend to ins Hollow cross (Lumbar lordosis) fall. The physiotherapeutic measures then serve as a posture school Force build-up e.g. the back musclesr and to promote mobility. Balance and coordination exercises are also helpful. Regular physiotherapy is already showing significant success after 6 months and can be completed after one to two years.

Has failed despite conservative measures such as physiotherapy, stand as Alternative to correcting the misaligned foot orthoses, plaster casts or splints for the night available. If the tiptoe has not grown together in childhood and persists into adulthood, problems with the back, the hips and the knees usually arise due to incorrect loading. Here again there are different starting points for physiotherapy. Above all, strengthening the right muscles to compensate for incorrect posture is relevant here. In physiotherapy, attention is also paid to the to learn the wrong posture learned and to learn the physiological gait again. This process can be lengthy, but in the long run it is the only chance of freedom from complaints.

Osteopathy

In addition to physiotherapy, too osteopathic strategies to be helpful. The tiptoe is often accompanied by restricted mobility of other joints, especially the upper ankle. At best, the osteopath detects this and acts accordingly. Bad posture e.g. of the back can be treated using osteopathy.

Wahrnehumgsstörung

Children who prefer toe walking have often Difficulty finding the balance in the normal state. In this regard, there is a disturbance in the perception of equilibrium. However, this can be trained and optimized with various exercises. Some children tiptoe in situations where they are under high stress, excitement or fatigue stand. The tiptoe is situational in these children. You can try the Change perception regarding such triggering situations and adequate strategies e.g.. against To develop stress. Some children with a toe tip show a correlation to other disorders. In some cases, the children have weaknesses in concentration or other abnormal behavior.

insoles

There are specially developed inserts for the toe tip therapy, which Pyramid inlays after Pomarino ® . The insoles are adjusted individually for each child. The foot is particularly supported by this insert and gets new support. Overall, the material is very resilient, which is especially important for the heavy forefoot load when walking on tiptoe. The insoles not only have a direct positive effect on the foot, they also have an indirect effect on the tendons and muscles.

Summary

The idiopathic clubfoot "grows" in many cases even without medical intervention in childhood. The specialist doctor (usually an orthopedist) decides when therapy is necessary and when regular check-ups are sufficient..

In early therapy, special ones are often used pyramid deposit used. These are individually adapted to the foot and are intended to force it into a normal position. Through physiotherapy and certain stretching exercises, an additional shortened Achilles tendon be treated. This treatment of the idiopathic tiptoe is after approx. 6 to 24 months completed and has a very good forecast.

Step through this no sufficient improvement, so with the help of orthoses, plaster or rails tries to achieve a normal position. Often contracted calf muscle can be relaxed by an injection of botulinum toxin (botox). An operative extension of the shortened Achilles tendon however, is rather rare.

course

The course depends on the underlying disease and its treatment options from.

In the idiopathic Toe walking In half of all cases there is a complete normalization of the gait without treatment.

That remains Toe walking Preserved into adulthood, widening forefoot and hollow feet often occur.

The consequence of abnormal stress on certain muscle groups and the skeleton can be premature wear and tear deformity of the hip, knee or ankle. Type III in particular has a high spontaneous healing rate, types I and II treated in good time also have an excellent prognosis. This is best when the treatment before the age of 5 late effects are then not to be expected. In addition, treatment is very effective, but it can be lengthy and time-consuming.