Orthotists and prosthetists now have data confirming there are available options to effectively treat idiopathic toe walking other than the standard AFO with a plantar stop.
Coauthors Kinsey Herrin, MSPO, CPO/LPO, practitioner at Ortho Pro Associates in Miami, and Mark D. Geil, PhD, associate professor of kinesiology and health at Georgia State University conducted a parallel randomized controlled trial with 18 children aged 2 years to 8 years with a diagnosis of idiopathic toe walking (ITW) to determine whether different orthotic treatment options for ITW resulted in similar outcomes. They randomly assigned nine children each to an articulated AFO with a plantarflexion stop or to a rigid carbon fiber footplate attached to a foot orthosis.
Control of toe walking
“As clinicians, we already know that an AFO controls toe walking well when a patient is wearing it,” Herrin said. “What we do not see as clinicians is what happens when a kid walks out of our office, and in the case of ITW, we want to stop the toe walking as quickly and easily as possible so that a child is not wearing a device for an extended period of time.”
The researchers excluded any children with a neurologic condition, those with previous treatment for Achilles tendon contractures and those with a plantarflexion contracture. At baseline and at 6 weeks of treatment, children completed 3-D gait assessment and the L-Test of Functional Mobility. Parents completed a satisfaction survey and a subset of the Orthotic and Prosthetic User Survey (OPUS) after children were treated.
Results revealed significant improvement in kinematics from baseline to 6 weeks of treatment in both groups; both orthoses controlled and reduced the amount of toe walking from baseline when the children were wearing the orthoses.
“However, when we removed the orthoses and re-measured the patients’ gait, we saw that the foot orthosis with the rigid footplate had better carryover in reducing toe walking than the AFO,” Herrin said. “Parents also indicated through the OPUS that they preferred the foot orthosis with the rigid plate for its appearance and skin friendliness.”
Biomechanical, sensory considerations
Children in the AFO group walked significantly faster than children wearing the foot orthosis with the rigid plate at follow-up. The researchers found no difference in cadence or step length between the two groups. At baseline, of the 1,682 steps assessed across all children, 20% showed initial contact with the forefoot while 80% showed initial contact with the heel or with a flat foot. At follow-up, researchers assessed 1,495 steps in the orthosis condition and 1,461 steps in the shoes-only condition, and they found some differences between the treatment groups: AFOs were 100% effective at preventing initial contact with the toe, but in the group wearing the foot orthosis with the rigid plate, 13% of steps with the orthoses worn showed either flat-footed or toe contact.
“We were expecting the kids with the AFO to perform better following removal of the orthoses simply because the biomechanics of an articulated AFO with a plantarflexion stop control toe walking so well in the clinic,” Herrin said. “But the reality with an ITW diagnosis is there is a sensory component involved that we do not really understand. We are not just treating a simple biomechanical problem with ITW, so a less invasive device like the foot orthosis with a rigid plate can work to help train a child over time to walk normally.”
Tailoring solutions for individual patients
To the authors’ knowledge, this study is the first to use a single intervention for ITW. In other studies, according to Herrin, multiple interventions, including Botox, serial casting, orthoses and physical therapy were administered together, which makes it difficult to determine and compare the effectiveness of individual interventions or combinations of interventions. The researchers also controlled for the individual design of each orthosis so that each child received a custom device with the same specifications.
“Any orthotist who wants to expand on our results could fabricate the devices in the same way we did,” Herrin said.
She added there is still a place for AFOs, especially in cases of severe toe walking or a long-term habit.
“But from our study, we now know there are other options that can successfully curb the toe walking,” she said. “Orthotists/prosthetists know that each patient we see is an individual, so there are not cookie-cutter solutions for a single diagnosis. [There] is still much an artful practice for treating ITW where individual differences must be considered when coming up with an appropriate orthosis design.” – by Tina DiMarcantonio
- Herrin K, et al. Prosthet Orthot Int. 2016;doi:10.1177/0309364614564023.
Disclosure: Herrin reports no relevant financial disclosures.