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Toe Walking:

- Discussion:
    - main causes of toe walking are idiopathic toe walking and cerebral palsy
    - history may include continuous toe walking vs normal gait followed by delayed toe walking by age 2 yrs;
    - idiopathic toe walking is often caused by a congenitally short heelcord or an overactive calf muscle;
    - heel cord lengthening may be an option after age 3 if there is no improvement in symptoms;
    - in the report by Policy JR, et al (2001), the authors investigated whether children with mild spastic diplegic CP could be differentiated from those with idiopathic toe-walking (ITW) based on an obligatory coactivation during voluntary contraction of the quadriceps or gastrocnemius;
           - 24 subjects participated in this study, 8 children with mild spastic diplegia CP, eight with ITW, and 8 age-matched controls;
           - measurements included passive range of motion and surface EMG recordings of the lateral quadriceps and lateral gastrocnemius;
           - EMG recordings were obtained during resisted knee extension with knee flexed 30°, isometric quadriceps contraction with knee extended (quad set), active plantarflexion, and during gait;
           - range-of-motion values were not different between the CP and ITW subjects, with the exception of the popliteal angle, which was greater in subjects with CP, with an overlap in values;
           - gait electromyography showed premature firing of gastrocnemius in swing in both groups of subjects compared with controls;
           - during resisted knee extension and quad set, the mean duration of gastrocnemius coactivation in subjects with CP was high: 86% and 86% compared with 20% and 35% for the subjects with ITW and 0.4% and 3% for controls, respectively;
           - voluntary plantarflexion did not consistently elicit coactivation of the quadriceps;
           - results suggest that electromyographic testing of resisted knee extension and quad set to identify gastrocnemius coactivation can help differentiate patients with mild CP from those with ITW;
           - ref: Electromyographic Test to Differentiate Mild Diplegic Cerebral Palsy and Idiopathic Toe-Walking 
    - in the report by Kogan M and Smith J (2001), the authors managed children with ITW using an outpatient percutaneous lengthening of the Achilles tendon, followed by placement of below-knee walking casts for 4 weeks;
           - authors reviewed 15 children who were treated for ITW with percutaneous Achilles tendon lengthening between 1993 and 1999;
           - 10 of the 15 patients could be contacted for a follow-up survey;
           - none of the parents stated that their child's toe-walking had recurred;
           - all of the children were able to keep up with other children and did not notice any calf weakness;
           - 2 children had occasional Achilles tendinitis, which was relieved with antiinflammatory medications;
           - ref: Simplified Approach to Idiopathic Toe-Walking