A Retrospective Analysis of Nonoperative Treatment Techniques for Idiopathic Toe Walking in Children: Outcomes and Predictors of Success

Abstract

Background: The lack of consensus regarding optimal nonoperative management of idiopathic toe walking (ITW) results in wide variation in treatment across providers and institutions. Untreated toe walking can cause persistence of abnormal gait and symptomatic foot deformity in adulthood. Objective: To examine the outcomes of multiple commonly used nonoperative treatment techniques in a large cohort of children with ITW to better inform management of this condition. Design: Retrospective cohort study. Setting: Single tertiary care children's hospital from 2008 to 2015. Patients: Two hundred four children with ITW, aged 4 to 7 years at time of diagnosis, nonoperatively managed in orthopedic surgery, rehabilitation medicine, neurodevelopmental medicine, neurology, or physical therapy clinics. Interventions: Nonoperative techniques included observation, home stretching program, physical therapy program, use of anklefoot orthoses (AFOs), and serial casting. Main Outcome Measures: Greater than or equal to 10 of ankle dorsiflexion with the knee extended or walking on toes less than 25% of the time at last visit. Failure of treatment was defined as not achieving resolution criteria or requiring surgical intervention following failed nonoperative management. Results: Only 121 children (59.3%) attended at least one follow-up visit. Of those, 55 (45.5%) had a successful outcome. Increasing severity of ITW was associated with increased rate of follow-up (P = .03) and lower rates of successful treatment (P = .03). The use of AFOs was the only treatment modality associated with a successful outcome (unadjusted/adjusted odds ratio 3.97; [95% confidence interval, 1.80-8.74] and 4.81 [95% confidence interval, 1.91-12.1], respectively; P = .001). Conclusions: Loss to follow-up is common in children with ITW. Of those children who returned to clinic, less than half had a successful outcome. The only treatment technique statistically associated with short-term resolution of toe walking was the use of AFOs.

Idiopathic Toe-Walking: A Review from 1967 to 2021

“…Wearing AFOs was only individual treatment as well as when used in conjunction with others to demonstrate a significant relationship with successful outcome. 33…”

“…8,16,24,45,52,64 Others included participants with developmental issues and listed the coexisting deficits/problems, e.g., learning disability/difficulties, speech delay, fine motor delay, visual perceptual deficit, autism, hyperactivity, and psychomotor delay. 12,30,33,53 By follow-up at 10 years of age, 10 out of 26 healthy active toe-walkers at 5.5 years of age were given an additional diagnosis, including dyslexia, attention deficit hyperactivity disorder, gross motor delay, and language delay. 5 Discussion ITW was consistently described as a diagnosis of exclusion.…”

“…A retrospective review of several CO found that AFOs alone or when used in conjunction with other interventions were associated with the successful outcome. 33 Effectiveness of orthoses has not received adequate attention, including exploring age of initial application and various durations of use, to draw any conclusions.…”

“…The diagnosis of idiopathic toe-walking (ITW) is reserved for children who walk on their toes, 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 make initial contact (IC) with toes/forefoot, 24 25 26 have toe–toe gait pattern, 27 28 29 30 31 or have the absence of heel strike. 1 14 20 23 31 32 33 34 35 36 37 38 39 40 41 42 43 It is one of exclusion, in which no known neurological, neuromuscular, orthopedic, or neurodevelopmental cause, e.g., cerebral palsy (CP), muscular dystrophy, or autism, can be found for the patient's condition.…”

“…6 8 9 10 12 13 19 22 30 45 49 52 53 55 Often the sample was only defined as participants with ITW/diagnosis of ITW. 1 4 5 7 11 15 16 21 26 27 28 29 32 33 34 36 37 38 40 46 50 54 57 58 59 60 61…”