About Toe Walkers...

Photo courtesy of Surestep

Idiopathic Toe Walking in kids..Is it flexor dominance?

You see this at times in the office. Kiddos (or adults) who walk on their toes for no apparent reason. many have shortened heel cords with limited ankle dorsiflexion (1,2). Some studies report an incidence of 7-24% in pediatric populations (3) with an average of about 5% in children that are 5.5 years old (4). It seems to occur in about 2% of normally developing kids aged 5.5 years and 40% of those that have some sort of neuropsychiatric diagnosis or missed a developmental window (5-7), with an increased incidence familialy (8). The question here is why, not what.

We have discussed our opinions of flexor dominance here many times and suffice it to say that increased corticospinal activity seems to have the double whammy effect of increased firing of the distal flexors due to a lack of input to the axial extensors in the rostral and caudal reticular formations respectively(possibly from decreased spindle and /or GTO input and/or mechanoreceptor dysafferentation?) and lack of reciprocal inhibition of the extensors from the increased firing of the flexors segmentally. Is it the cortical abnormailities and missed developmental windows seen in so many of these folks that drives this? These are the sorts of things that keep us up at night....

Physical treatment modalities (2) seem to help, we think most likely to plastic changes in the connective tissue. Orthotics may prove useful due to similar mechanisms, especially if there is an equinus deformity or forefoot to rearfoot abnormaility (9). More agressive (and invasive) measures like Botox, seem to not. An interesting study using whole body vibration (10) produced some immediate but short lived positive results. This really gets you thinking about joint and muscle mechanoreceptors and the cerebellum, and makes us think that perhaps we also should be looking (and treating) north of the foot. We could not find any studies looking at the effects of proprioceptive or vestibular exercises effects on this, but think it could be promising area of therapy and we will continue to employ them until our clinical results tell us otherwise. 

1. Barrow WJ, Jaworski M, Accardo PJ. Persistent toe walking in autism. J Child Neurol 2011;26(5):619-621

2. Harris NM. Multidisciplinary approach led to positive results for pediatric patient with idiopathic toe walking. Presented at the Association of Children’s Prosthetic-Orthotic Clinics Annual Meeting, Broomfield, CO, April 15, 2016.

3. Engelbert R, Gorter JW, Uiterwaal C, et al. Idiopathic toe-walking in children, adolescents and young adults: a matter of local or generalised stiffness? BMC Musculoskelet Disord. 2011;12:61.

4. Engström P, Tedroff K. The prevalence and course of idiopathic toe-walking in 5-year-old children. Pediatrics 2012;130(2):279-284.

5. https://tmblr.co/ZrRYjx1VV59rl

6. Williams, C. , Curtin, Wakefield and Nielsen Is idiopathic toe walking really idiopathic ? The motor skills and sensory processing abilities associated with idiopathic toe walking gait.  J Child Neurol 2014, 29:71

7. https://tmblr.co/ZrRYjx1WTNcdK

3. Is idiopathic toe walking really idiopathic ? The motor skills and sensory processing abilities associated with idiopathic toe walking gait.  J Child Neurol 2014, 29:71 Williams, C. , Curtin, Wakefield and Nielsen

8. Pomarino D, Ramirez Llamas J, Pomarino A. Idiopathic toe walking: tests and family predisposition. Foot Ankle Spec 2016;9(4):301-306

9. Herrin K, Geil M. A comparison of orthoses in the treatment of idiopathic toe walking: a randomized controlled trial. Prosthet Orthot Int 2016;40(2):262-269.

10. Williams CM, Michalitsis J, Murphy AT, et al. Whole-body vibration results in short-term improvement in the gait of children with idiopathic toe walking. J Child Neurol 2016;31(9):1143-1149.

More on landing mechanics.
Here is a recent article on landing mechanics. This article talks about the landing mechanics far past where I feel the first stage of vulnerability is, which is initial forefoot load, as i discuss in the video pertaining to landing from a jump or if sprinting (forefoot loading). IF landing occurs in low gear (lateral half of the forefoot), inversion risks are higher.
The medial foot tripod, high gear toe off (1st and 2nd mets) is where we should be taking off from, and landing initially upon. Anything lateral is vulnerable without the lateral column strength (lateral gastrocsoleus complex, peronei longus/brevis).
This article talks about knee flexion angles and ACL vulnerability, far after this initial loading response. The article some valid conclusions in that phase.

- Dr. Shawn Allen

Posture specific strength and landing mechanics.

http://lermagazine.com/article/posture-specific-strength-and-landing-mechanics

https://www.youtube.com/watch?v=8T9UzOaYxmo

Podcast 84: Toe Walkers, Hip Impingment & Olympic Lifting Shoes

Plus: pulmonary edema syndrome in Triathlete swimmers, truths about olympic lifting shoes and more !

Show sponsors:

www.newbalancechicago.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_84f.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-84

Other Gait Guys stuff

B. iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:

Monthly lectures at : www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

Show notes:

Are Triathletes Really Dying of Heart Attacks?

http://www.outsideonline.com/fitness/triathlons/The-Fatal-Risk-in-Triathlons.html

 

We had some stuff on FB last week about head positioning during running.  Alot of people tried to simplify it.  There is more to it. Here is another perspective.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2736108/

 

Toe Walking children

http://thegaitguys.tumblr.com/post/103571941844/toe-walking-in-children-do-you-know-what-you-are

 

Olympic lifting shoes ? or Converse Chuck Tailors ?

http://www.t-nation.com/training/olympic-shoes-or-chucks-for-squats

 

Journal of Foot and Ankle Research | Abstract | The associations of leg lean mass with foot pain, posture and function in the Framingham foot study
http://www.jfootankleres.com/content/7/1/46/abstract

 

Hip Impingements

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4223291/#B14

 

Achilles oddity: Heeled shoes may boost load during gait | Lower Extremity Review Magazine
http://lermagazine.com/news/in-the-moment-rehabilitation/achilles-oddity-heeled-shoes-may-boost-load-during-gait

 

http://www.mensjournal.com/health-fitness/exercise/how-to-injury-proof-your-body-20141114 

Toe Walking in Children. Do you know what you are dealing with ? Part 2

So you have now ruled out possible Autism-spectrum, possible CMT (Charcot-Marie Tooth Disease), CP (Cerebral Palsy), MD (Muscular Dystrophy) in your young toe walking individual.  Now you have been left with the aftermath foggy diagnosis of “Idiopathy Toe Walking”, that doesn’t leave you as a parent or clinician with much to work with or likely to be confident about. Let us try to help make things clearer and give you some other cognitive options to entertain. New research in recent years has brought new light onto the issue and we wanted to use today’s blog post as a platform to share it with you. 

In a previous week’s “Part 1” blog post & video (link) you can see in the gait on the video that nothing appears to be terribly abnormal in the foot structure (from what we can tell), the client is merely remaining in the plantarflexed posture and forefoot weight bearing.  This is highly ineffective gait and can be very fatiguing let alone to mention the sustained loading into the posterior compartment and plantarflexor mechanism (gastrosoleus-achilles) not to mention the sustained forefoot loading response on the foot bones and joints. Remember, the tibialis posterior and long toe flexors are close neighbors with capabilities of plantarflexion moments, so there are possible clinical manifestations there as well not to mention the obvious (especially to long-time Gait Guys readers) deficits that will be found in functional ankle dorsiflexion, ankle rocker and S.E.S. (skill, endurance, strength) of the anterior compartment mechanism (tibialis anterior, long toe extensors, peroneus tertius).  Even if this client were to go into normal heel strike and stance phases right now, they would have lots of work to do to restore the anterior-posterior compartment balance, the 3 foot rockers (heel, ankle and forefoot) abd posterior compartment length to avoid functional pathology not to mention the timely coordination of all these events. 

Idiopathic toe walking is suggested to be as prevalent as 12%. Toe walking is categorized when there is an absence, or at least a limitation, of heel strike during initial walking gait contact phase. We are not referring to, at all, forefoot running principles. Neuromotor maturation comes about via the suppression of the primitive reflexes/windows and appearance of the postural reflexes and responses. Delays or subtractions of these windows/reflexes may cause challenges in the normal development and maturation of the central and/or peripheral nervous systems.  With toe walking, the clinical window most studies suggest is to begin investigation after 3 years of age when the primitive motor patterns should have solidified and the gait and postural patterns have begun to layer on top of those primitive reflexes.  Remember though, the primitive patterns are not sequentially fixed, meaning that infants move in and out of these reflexes until they become skilled and permanent.  It is not until they are fixed that the postural patterns, which are volitional, can be gradually built. This should bring some deeper thoughts to your mind right now.  Is toe walking behavior a missed primitive window or a non-volitional postural window? These kids are not doing this by choice, anyone who has worked with these types of cases knows this very well, and we have seen our share. 

In the literature and clinics a plethora of things have been tried and discussed (ie. serial casting, botulinum toxin, surgical tendon lengthening, gait retraining, orthoses/orthotics, night splints, day splints and the like). Keep in mind that only one of the above is addressing a functional change via cognitive and higher brain center demand, “gait retraining”. The others are passive forced attempts.  But is gait training enough ? And how far back into primitive and postural gait pattern training do you have to go? Gait training certainly does something as eluded to by two research papers we posted on our Facebook page in previous weeks. See those references below.

“For both feet, contact time of the heel was increased after the training period, whereas contact time of the forefeet decrease. Also positive changes in the active range of joint motion of the ankle (dorsal extension) were observed in both feet. These positive effects were visible also in the follow–up assessment.” -Pelykh study

“Daily intensive gait training may influence the elastic properties of ankle joint muscles and facilitate toe lift and heel strike in children with CP. Intensive gait training may be beneficial in preventing contractures and maintain gait ability in children with CP.” - Willerslev-Olsen study

So what else could be going on here ? Is this neurodevelopmental ? Yes, for sure.  But where did things go awry ?  And how do we fix it ? Remember, the development of primitive and postural reflexes is supposed to occur proximal to distal (ie. from core to hand/foot).

In a recent study in the Journal of Child Neurology,  

“for the first time, motor and sensory challenges presenting in healthy children with an idopathic toe walking gait have been identified.These challenges imply an immaturity or mild impairment at the cerebellum or motor cortex level.”

As the article suggested, the research did not render direct cause(s) for the gait pattern, rather some very viable theories on the topic. They found that only the areas of balance, upper body coordination and bilateral coordination were areas found to be problematic in the toe walkers. These 3 components require the integration of the tactile, vestibular and proprioceptive systems as a team. Diving deeper into how these 3 outputs are linked, there is a required “mix of occulomotor control and cues together with subtle and gross postural adjustments” (3). As Williams et al (3) suggested, “they are skills requiring the coordination of movements in which each side of the body moves simultaneously or in sequence”.  Kind of sounds like some topics on Arm Swing/Leg swing and also on the topic of phasic/antiphasic gait we have discussed over and over again here on TGG and in recent podcasts (82) doesn’t it ?  It was proposed that perhaps idiopathic toe walkers negotiate their sensory challenges by unconsciously engaging toe walking behavior to change or challenge these inputs.  Here were some of the proposed thoughts from the Williams study.

“The tactile receptors of the skin may be stimulated through pressure at the ball of the foot or lessened by a reduction of surface contact by raising the heel off the ground. Proprioceptive input may be changed at the knee, ankle and even toe joints by unconsciously repositioning of the foot posture.  The vestibular input may be increased by the vertical stimulation of the bouncy type gait that results from toe walking.”(3) Williams

It seems clear from the Williams study that these children demonstrate a number of sensory needs that motivate toe walking to alter (increase or decrease) or improve sensory input.  The study also suggests that the toe walking gait is an attempt to modify input on postural stimuli during gait to serve diminished postural and position awareness.

The findings of this study are important.  Our most recent blog posts and podcasts (Nov 2014) have discussed some of the components to build, control and coordinate gait on a higher neurologic level. The Williams article seems to support these discussions, that some pathologic gaits are initiated on a neurologic level as opposed to biomechanical at the foot and ankle level.  This sounds like the work offered by “the functional neurologist”, graduates of the Carrick Institute for Graduate Studies ! (carrickinstitute.com)

Have a great day gait brethren !

Shawn and Ivo, The Gait Guys

References:

1. Eur J Phys Rehabil Med. 2014 Oct 9. [Epub ahead of print]

Treatment outcome of visual feedback training in an adult patient with habitual toe walking.

Pelykh O¹, Klein AM, Feist-Pagenstert I, Schlick C, Ilmberger J.

NeuroRehabilitation. 2014 Oct 15. [Epub ahead of print]

2. Gait training reduces ankle joint stiffness and facilitates heel strike in children with Cerebral Palsy.

Willerslev-Olsen M1, Lorentzen J1, Nielsen JB2.

3. Is idiopathic toe walking really idiopathic ? The motor skills and sensory processing abilities associated with idiopathic toe walking gait.  J Child Neurol 2014, 29:71 Williams, C. , Curtin, Wakefield and Nielsen

The Bouncy Gait: Premature heel rise gait. Taking another look.

This is a great video example of a premature heel rise during gait. You should be able to clearly see it on the left foot (and this was toned down after we brought it to his awareness!).  The heel rise occurs early in the stance phase of gait, instead of the late stance phase.

We have talked about this bouncy type vertically oriented gait many times in blog posts and in our podcasts.  This is a pretty prevalent problem in the world, mostly because so many people have impaired ankle rocker/dorsiflexion from weak anterior compartments and short/tight posterior compartments.  None the less, for the majority, this is a pathologic gait pattern and it will impart undue stress into the posterior mechanism (calf-achilles complex). Just think about it, this person is going vertical at or prior to the tibia achieving 90degrees (perpendicular to the ground) instead of continuing to progress the tibia to 110+ degrees to enable normal timely pronation and foot biomechanical events.  This is not a normal gait. Period. This will change the function of the entire posterior chain upward. 

If you want to see another great example  from the frontal plane, check out this cute video representation of a vertial/premature heel rise bouncy gait. 

This gait style is caused by a premature heel rise from joint range limitation and/or from premature engagement of the gastrosoleus (and sometimes even the long toe flexors, you will see them hammering and curled in many folks). It can be a learned habitual pattern and nothing more, we have even seen it even in child-parental gait modeling in our offices. These people will never get to NORMAL full late-midstance of gait (without biomechanical compromise) and thus never achieve full hip extension nor adequate ankle dorsiflexion / ankle rocker. The gait cycle is an orchestrated symphony of timely events and when one or several timely events are omitted or impaired the mechanics are passed into other areas for compensation. This vertical gait style is very inefficient in that the gluteals cannot adequately power into hip extension into a forward progression drive, because the calf is prematurely generating vertical movement through ankle plantarflexion.  This strategy is sometimes deployed because the person actually is significantly ankle dorsiflexion (ankle rocker) deficient.  Meaning, they hit the limitations of dorisflexion and in order to progress forward they first have to go vertical.  This vertical motion, because they are moving into ankle plantarflexion, re-buys more ankle dorsiflexion range which then can be used if they so choose. Obviously, the remedy is to find the functional deficit, remove it and retrain the pattern.  There are a whole host of other problems that go with this compensation pattern but we wanted our mission to stay focused today.  Remember, this is usually a subconscious motor pattern compensation. Is it like the toe walking issue we talked about last week (post link here) ? It is similar in some ways and can have primitive and postural motor pattern implications. We will follow up the “Idiopathy Toe Walking Gait: Part 2” shortly but we wanted to strategically put this blog post ahead of it, because there are similar characteristics and implications. Trust us, there is a method to our madness :)

Shawn and Ivo

The Gait Guys

Podcast 37: Anandamide & Body Work, 3D Printed Shoes and Case Studies

Our show notes should interest you today. We have another great podcast ready for you today !

Link to our server:

http://thegaitguys.libsyn.com/podcast-37-anandamide-body-work-3d-printed-shoes-and-case-studies

iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

Gait Guys online /download store:

http://store.payloadz.com/results/results.aspx?m=80204

other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  "Biomechanics"

Today’s show notes:

Neuroscience piece:

McPartland et al (2005) measured Anandamide (AEA) levels pre- and post, Myofascial Release, Muscle Energy Technique, High velocity manipulation all of which load fascia patients experienced analgesic/euphoric cannabimimetic effects, which correlated with an increase in serum AEA levels (more than double pre-treatment evels). 

Neither cannabimimetic effects, nor changes in AEA levels, occurred in control subjects.

McPartland, J et al 2005.. Jnl. American Osteopathic Association 105, 283–291 
http://leonchaitow.com/2008/01/30/bodywork-high

2. Vibrating shoes could be the future of navigation and wearable tech

http://www.wired.co.uk/magazine/archive/2013/09/start/vibrating-shoes-the-new-navigation-tool

3. Tim Ferriss (@tferriss)

9/2/13 9:25 PM
Malcolm Gladwell: “Man and Superman” The New Yorker buff.ly/174jruO Drugs, genetics, and the fallacy of a level playing field.

 

4.FB reader sent us a message:

Hi Guys: Not quite sure how I came across your podcasts but really enjoying them, even if I’m only slowly starting to understanding them. I was catching up on some old ones during my marathon training and the ones on evolution reminded me of some of my musing on the arch in the foot (well I guess correctly that should be the medial longitudinal arch). I though you might be able to give me the answers or point me in the right direction

Are we only species with this?

What is the advantage?

When and how does it develop and why isn’t it formed in utero?

Are flat feet then a genetic or developmental issue and why?

Thanks 

Alex

5. off the web:

The imprecise art of foot orthoses

http://www.americaspodiatrist.com/2011/02/the-imprecise-art-of-foot-orthotics/

6. off the web:

3D-Printed Shoes Mean You’ll Never Need to Buy Another Pair
http://mashable.com/2013/08/20/3d-printed-shoes/

7. Another TUMBLR reader asks question about:

Hi Gait Guys,

I am currently a third year podiatry student needing some biomechanics and orthotic-making training. I enjoy your youtube videos but was wondering if you offer or could recommend a dvd that I could purchase to further my education. The way the information is presented it in class is not as good as the way you do it! I am also interested in the biomechanics of shoes… I am having trouble finding information about how walking in a cushioned/plantarflexed sneaker effects function (Does is help us get to forefoot running or hinder us?). I enjoyed your blog on different curved lasts as well. How would I be able to apply the way the shoe is lasted to a patient? For example, if the patient is rigid and I want them to be wearing a shoe that is lasted like a slipper how do I guide them into buying a shoe constructed as such? Do I just tell them to go for a shoe made with a straight toe box? Is there such a thing as a toe box curved laterally? 

One last question- do you recommend a medial FF post for a patient that has a mobile RF varus that causes a FF supinatus? I was told a post like this would limit PF of the first ray and DF of the hallux which would limit toe off and cause other problems. 
Thank you. I appreciate any advice you may have. I am out of my element with biomechanics and really want to improve at it.

8.Another off tumblr: 

sign-life-away asked you:

Is forefoot walking bad for you? Everyone says I walk awkwardly, as if i have something up my bum. I have been trying to walk “naturally” (heel-toe) but I go back to forefoot strike. Does this contribute to why my legs have always been muscular?

Lets test your visual skills again.

This is a 7 year old with gait abnormalities that has hypertrophied calves and difficulty with attention span (what 7 year old doesn’t) and being “slightly behind in learning”. This young lad was brought in by his mom because other therapists had felt they had reached an end point of care and was offered little from the allopathic physicians they visited.

Watch his gait cycle several times and see if you note the following:

• exaggerated upper body movement
• increased progression angle (r foot particularly)
• toe walking gait
• wide base of gait with running

Physical exam findings reveal

·       cavus foot

·       ankle dorsiflexion at 0 degrees

·       intact lower extremity reflexes, sensation and motor strength

·       general weaker upper body strength (particularly shoulders)

Rather than play “name the pathology”, lets concentrate on what we would do for this young man.

·       Increase ankle dorsiflexion and ankle rocker

·       Increase hip extension and gluteal recruitment

·       Increase proproioception

·       Increase coordination

·       Increase upper body strength

The Gait Guys. Helping you to see things more clearly and find solutions to complex gait challenges.

Special thanks to JM for allowing us to present this teaching case.

Podcast 33: Heart Beats, Toe walking & Crawling

podcast link:

http://thegaitguys.libsyn.com/podcast-31-walking-straight-matalgia-queen

iTunes link:

http://thegaitguys.libsyn.com/podcast-33-heart-beats-toe-walking-crawling

Gait Guys online /download store:

http://store.payloadz.com/results/results.aspx?m=80204

other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen  Biomechanics

Today’s show notes:

Neuroscience Pieces:

1.Superhuman sight and hearing.

http://mashable.com/2013/05/06/mask-superhuman/
http://vimeo.com/58771063#

2. Kickstart device

http://www.gizmag.com/kickstart-kinetic-walk-assist/24255/

Kickstart from Cadence Biomedical is designed to help improve the gait of people who have difficulty walking and help them regain their mobility and independence. But unlike its robotic cousins that are powered by weighty rechargeable batteries, the Kickstart is able to ditch the batteries altogether because it has no motors to power. Instead, it is purely mechanical and provides assistance by storing and releasing kinetic energy generated by a person when walking.

3. Bionic ear
Scientists have created a 3D-printed cartilage ear with an antenna that extends hearing far beyond the normal human range.
In general, there are mechanical and thermal challenges with interfacing electronic materials with biological materials,“ said Michael McAlpine, an assistant professor of mechanical and aerospace engineering at Princeton and the lead researcher. "Previously, researchers have suggested some strategies to tailor the electronics so that this merger is less awkward. That typically happens between a 2D sheet of electronics and a surface of the tissue. However, our work suggests a new approach — to build and grow the biology up with the electronics synergistically and in a 3D interwoven format.”

http://www.cnet.com.au/printable-bionic-ear-sends-hearing-to-the-dogs-339344149.htm

http://www.runnersworld.com/health/how-many-heart-beats-do-we-get

4. Blog reader asks:
I recently came across “The solitary externally rotated foot”, as well as the Cross Over Gait, and Applied Gait Hip Mechanics videos. First of all, your material very insightful, so thank you! I am an amateur runner that exhibits external foot rotation and cross over running, which I suspect causes my hip pain (where the GMed joins the femur) over long distances. Curiously, this pain completely disappears when running up hill. Is this an anomaly, or does the slope correct my gait somehow?

5. FACEBOOK readers asks:
Dayle

• HI: Can you tell us what role the gluteus medius plays in foot pronation. What if they are weak or tight? And how about the QL, too? Would a foot supinator have weakened QLs (they don’t get to work much) and a foot overpronator have over-worked/loaded QLs (controlling spin)? And hey, if I toss in functional scoliosis in the lumbar region to this mix, well, what a tight mess I have, eh? Any insights on how to become unscrewed?

6. Karis

• Hi there, I’m sure you get 100,000 messages so thank you for your time for reading this! Today I had a revelation that I have external tibial torsion. After much googling about my knees turning in quite a lot when my feet are straight I finally found it! Then I found your blog on Tumblr and read all about it and watched the videos. I just wondered if you had any advice on running, I am keen to start running but I didn’t know whether to run with my feet sticking out as my natural position or anything else I should be doing? I also wondered if it can be corrected marginally by doing any strength exercises? Thank you for your help in advance! Karis

 

7. PUBMED
Overtraining:
Some of the signs of overtraining may include an unexplained decrease in performance, changes in mood state, excessive fatigue, the need for additional sleep, frequent infections, continued muscle soreness and loss of training/competitive drive.

We have included an article that puts it into simple light for the athlete:
http://www.running-physio.com/overtraining/

J Nov Physiother. 2013 Feb 16;3(125). pii: 11717.

8. Toe walking in children
In most cases no etiology of toe walking is found. The medical literature considers it abnormal if it persists after 3 years of age. Idiopathic Toe Walking (ITW) is considered a diagnosis of exclusion and is employed only when all other possibilities have been eliminated with a meticulous clinical examination and various investigations. If any etiology is found, the treatment should be first non operative
The differential diagnosis in children who walk on their toes includes mild spastic diplegia, congenital short achilles,  and idiopathic toe walking (ITW).  A reduced ankle range of motion is common……one just needs to find the source of the reduction…….meaning funcitonal,  ablative (structural). Reported treatments have included serial casting, Botulinum toxin type A or surgery to improve the ankle range of motion.  Is there an immediate impact of footwear, footwear with orthotics and whole body vibration on ITW to determine if any one intervention improves heel contact and spatial-temporal gait measures.

BMC Musculoskelet Disord. 2011 Mar 21;12:61. doi: 10.1186/1471-2474-12-61.

9. Idiopathic toe-walking in children, adolescents and young adults: a matter of local or generalised stiffness?

Engelbert R, 

_______

10. J Foot Ankle Res. 2010 Aug 16;3:16. doi: 10.1186/1757-1146-3-16.

Idiopathic toe walking and sensory processing dysfunction.

11. Crawling May Be Unnecessary for Normal Child Development?

http://www.scientificamerican.com/article.cfm?id=crawling-may-be-unnecessary