Monday, February 25, 2008

Idiopathic toe walking

A case studied in our second-year medical school curriculum involves a boy with a tip toe gait. The differential diagnosis includes “idiopathic toe walking”. My lovely wife, Jennifer, thought that this topic might be of interest to our dear readers. Here’s an explanation of what is known about this disorder from the introduction to a 2006 paper from Hemo et al in the Journal of Pediatric Orthopedics:

“Persistent tiptoe gait after the age of 2 years in children without discernible neurological or orthopedic abnormality is termed "idiopathic toe walking" (ITW). This diagnosis is made after other disease processes have been excluded. The most common cause of toe walking in childhood is cerebral palsy; however, the differential diagnosis of toe walking includes conditions such as muscular dystrophies, tethered cord syndrome, diastematomyelia, and other neuromuscular diseases. Typically, patients with ITW commence this toe-to-toe gait at the initiation of walking, which occurs at a normal age. There is a positive family history in about 30% of cases.
If left untreated, this pattern of gait has a tendency to persist, and although initially, there is full passive dorsiflexion, an equinus contracture develops with time.”

By the way, according to MediLexicon.com “diastematomyelia” is defined as “complete or incomplete sagittal division of the spinal cord by an osseous or fibrocartilaginous septum.”

Full reference: Hemo Y. Macdessi SJ. Pierce RA. Aiona MD. Sussman MD. Outcome of patients after Achilles tendon lengthening for treatment of idiopathic toe walking. [Journal Article] Journal of Pediatric Orthopedics. 26(3):336-40, 2006 May-Jun.

15 comments:

Adam said...

Dr. Moore, is diastematomyelia a congenital condition? What is the incidence of this condition?

Brian E. Moore, MD said...

Hi Adam:
Diastematomyelia is another developmental abnormality of the spinal cord, in the same category as spina bifida. I don’t think the etiology is well understood. Here’s what Adams and Victor’s Principles of Neurology 8th edition (2005) has to say on the subject of all of these dysraphisms and malformations: “It would be intellectually satisfying if all the states that originate in the intrauterine period could be separated strictly into genetic (hereditary) or nongenetic forms, but in many instances the biologic information and the pathologic changes in the brain at this early age do not allow such a division. For example, among the many diseases in which the neural tube fails to close (rachischisis), more than one member of a family may be affected; but it cannot be stated whether a genetic factor is operative or an exogenous factor, such as folic acid deficiency, has acted on several members during a succession of pregnancies of one mother. Even what appears to be an outright malformation of the brain may be no more than a reflection of the timing of an exogenous process that has affected the nervous system and other organs early in the embryonal period, derailing later processes of development. Teratology, the scientific study of neurosomatic malformations, is replete with such examples.”

As for the incidence of diastematomyelia, it is a rare condition. However, according to a 2003 article in the journal Spine: “Diastematomyelia…. is reported to have an incidence of 1.8% to 16% in patients with congenital scoliosis.” (Ref: Uzumcugil A. Cil A. Yazici M. Acaroglu E. Alanay A. Akalan N. Ozisik P. Surat A. The efficacy of convex hemiepiphysiodesis in patients with iatrogenic posterior element deficiency resulting from diastematomyelia excision. [Journal Article] Spine. 28(8):799-805, 2003 Apr 15.)

Adam said...

Thanks Dr. Moore!

JD said...

Interesting.

ana said...

My child is 8. He has been toe walking since age 2. I was concerned and took him to a Dr.in Florida who recommended surgery. I had noticed that the toe walking improved when he was comfortable or in situations that were familiar to him. If I asked him to go do something like brush his teeth or get a napkin, he would walk normally and when I told this to the Dr. he did not believe me or really did not take any of my imput. He has sensory integration disorder. I have worked with him vastly and can tell you that the toe walking has diminish enormously. For anyone reading this, please get your children evaluated but Trust your instincts. I was always sure my son's case did not require surgery. I am happy I did the right thing. Kids don't really tease him when he does and I notice that he does it when he is nervous or in a new place..... Do your research parents!! No one knows our children like we do. My son underwent a surgery for adenoids and tonsils and he went on respiratory failure and was in the PICU for 6 days. Surgeries are not always the answer!

Brian E. Moore, MD said...

Interesting. Thanks very much for your comment, Ana.

Rainbow Rivers said...

Interesting blog article. We have been in the process of trying to find out what is wrong with our son. I have an older child who was born with cerebral palsy and was 2 and a half months premature when born. Now with our son he was born a tad on the small side and in the bottom 10 percentile. I crowned 3 times with him as he just did not want to come out. As soon as I would start to crown, my contractions would stop and he would get sucked back up. Anyways he was always clumsy, stiff and awkward but grew at a rapid rate and by the time he was 2 was in the top 98 percentile for height and weight. Everytime I brought up the stiffness and clumsiness, doctors would just shrug it off as his body was growing faster than his muscles could keep up. At age 8 an emergency physician asked if we had ever tested him for Muscular Dystrophy where again his pediatrician shrugged off as rapid growth. Now at 10 he developed toe walking and a couple months after the toe walking started, developed facial tics( the facial tics have almost stopped now)and has been undergoing every imaginable test we can do for our area where we do not have a pediatric nuerologist, it will be a 6 to 8 hour drive to get to one. They have done 3 MRI's on him, blood tests, range of motion and more checking for all the spinal bifida, muscular dystrophy, tethered cords and the like. They are leaning towards a mild case of cerebral palsy but do not like the fact it is showing up so late in his life. Anyways I have been doing tons of computer research myself trying to find some sort of clue and came across your article. I just wanted you to know I really appreciated reading it and hope we will find some answers soon even though it looks like a long trip for us in order to do so.

Kim said...

Question: My daughter is being seen by an orthopedic specialist this week. She appears to be positive for scoliosis. She is also a toe walker. One other bit of info: She was born with a pronounced and protruding skull where her head connects to her spine. A neurologist suggested this could be what causes the toe walking - which could also be a sign of mild palsey or she could have had a stroke in the womb which has caused growth around this area. the skull abnormality is not visible to the untrained but it is noticeable to touch. She is also very athletic and has complained of headaches when she does her sport (gymnastics). Does any of this sound related to the scoliosis?

Brian E. Moore, MD said...

To Kim,
The clinical scenario you described is out of my area of expertise. I wish I could give you more insight, but perhaps someone else reading your comment might post something that could help.
I wish you all the best,
BEM

Kim said...

thanks for your reply. We see the orthopedic specialist today. I'll let you know what comes up.

KL

Paul said...

Finally, for the last couple of hours I've been searching about Idiopathic toe walking and finally I stumble into your blog, it has great info on what I'm looking and is going to be quite useful on my paperwork for the university.
BTW is amazing how many generic viagra blogs I manage to dodge in order to get the right site and the right information...lol
Thanks for the post and have a nice day

melissa said...

Hello Dr Adam , my daughter was 25 weeks premature 1pound 10oz since she star walking she waslks on her toes she recived theraphy since she doctors recomended surgery achiles tendon lengthening they do test on her to see if it eas a neurological problem but she is ok also xrays everything wa snormal i need advice if is ok to wait or should i do surgey i would appreciated evrerybody opinion thanks.

MissE said...

Hi,
I have been taking my child to Scottish Rite Childrens Hospital for years. He is 9 years old. He has always walked on his toes. The delivery was normal. His MRI is normal. He functions normally although someone commented that their son had a facial tick? He does seem to have that sometimes. We've ruled out everything and did the heel chord lengthening. Nothing works. He is on his toes as high as he has ever been. I'm really out of ideas. He gets teased at school and has been as long as he's been in school. Just looking for answers everywhere....

Orleans said...

Dr. Adam,
Thank you for this blog. My child is 4. When she was 8 months, was detected neuroblastoma wrapping spinal column. Chemo last 6 months. Since she was 1, she have a toe walking. Do you see some relationship?

Anonymous said...

My daughter is now 13 years old and has been dealing with tip toe walking since she could walk.I started taking my daughter to doctors since she was 3 years old and they kept telling me that as she gains weight her heels will come down. That never happened. She is now having pain in her feet, ankles and knee on her left leg as the left leg is much much worse that the right leg. She cannot stand flat for more than 2 minutes on the left leg. After 5 mri's, physiotherapy and a achilles night splint we are opting for surgery as there does not seem to be any improvement. My daughter was born 5 weeks premature but was a normal birth and she is otherwise very healthy. She lacks co-ordination and is unable to squat.What prompted me to comment was the other comment from RAINBOW RIVERS about facial ticks..We took our daughter to the hospital when she was 7/8 years old with facial ticks...particularly around her eye. These ticks went away and after 6 months were gone and never recurred. I wonder if the facial ticks are relevant to the toe walking? The final diagnosis after so many mri's and appointments and physio and splints...."idiopathic toe walking" to be corrected by surgery. Good luck to all.