PT on the Net Research

Toe Walking


Question:

I've had a 14 year old client for a few months now who suffers from "toe walking" in his right foot, meaning that his right heel never touches the ground when he walks. This is something he's done all his life because he was born under developed (one pound, six ounces to be exact). He has performed tasks with "left side dominance" throughout his life. He's also had multiple surgeries on his right calf and Achilles tendon to attempt to lengthen them, and he wore a "corrective" foot device when he was younger to keep his calf muscle in a constant stretch. I've used self myofascial release to attempt to lengthen his calf, but it feels like it is to no benefit. I've had his parents roll him out every night as well to also attempt to lengthen it. Ankle flexion exercises have been implemented to attempt in strengthening his anterior tibialis. I've thoroughly instructed him to make every attempt to walk from heel to toe as much as possible. In spite of all of these exercises and stretching, it seems like hardly any progress has been made. Anything you could recommend would be greatly appreciated.

Answer:

Thank you for your question. I applaud your efforts as it sounds like you’ve done a lot to try to enhance your client’s function. Here is an additional strategy to incorporate. The following will be based on principles that can be applied to any client. In fact, a principle by definition is a fundamental assumption or a rule or law of nature. By following a principle-based approach, you won’t be “caught” guessing. Instead, you will be designing different strategies and techniques without confusion.

Structure feeds function and function feeds structure. Therefore, practically speaking, there is an interplay between structure (and known structural deficits) and function (what the person needs and wants to do). The following practically applies the principle to your client:

First, determine what your client needs to do and then ask, “What position is my client in relative to gravity (standing, sitting, kneeling, prone, supine, side lying)?” I’ll bet most of his needs deal with the position/motion of standing against gravity. Therefore, strengthening, balancing, etc., MUST improve in standing and not in a position that doesn’t relate to his needs (specific adaptation to impose demands principle). In addition, because your client most likely exhibits a structural deficit and it’s at the foot, his function is upright most of the time. From an application standpoint, you must balance this leg length deficit, or many dysfunctions will manifest (not a matter of “if” but a matter of “when”). “Why?” you may ask. A column (like the body) with a cross section that lacks symmetry will suffer torsional buckling (sudden twisting) before, or in combination with, lateral buckling. A column is twice as strong against a collapse if the top and bottom can rotate compared to the situation where the ends are not allowed to rotate. In your client’s case, if one leg is shorter, he most likely is “twisted,” which is an inefficient position from which to function.

With this being said, I would refer him to a podiatrist, physical therapist or someone who can look at your client’s foot structure AND entire body alignment to then design an artificial insert to give the foot/ankle what it doesn’t have. We only recommend artificial interfaces when all functional paths have been exhausted. I think in your client’s case this is a must before anything else. Good luck.