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Toe Walking
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Timmy is a sweet 5 ½ year-old boy presenting for evaluation of right sided toe walking. His mother notes that he started bilateral toe walking at approximately age two for no apparent reason. She initially “didn’t think much of it” because his brother Jimmy was a toe walker and eventually “grew out of it”. She brought this up to her pediatrician at around age three. His advice at the time was that toe walking is a normal variation and that it was likely to resolve spontaneously. His mother notes that initially he would toe walk infrequently and she could cue him to go “heel down”. However, she notes that his toe walking has gotten progressively worse. He only toe walks on his right side, but, he does it all the time and she can no longer cue him to walk with a heel strike.
PAST MEDICAL HISTORY
Timmy’s mother describes a normal birth history as well as a normal developmental progression with no history of language, intellectual, or motor delay. She reports Timmy has normal control of his bowel and bladder.
OBSERVATION
Timmy is a well-developed and well-nourished 5 ½ male. There is no calf atrophy or hypertrophy. His pelvis appears level, his spinous processes are grossly in line with one another, there is no posterior rib protuberance.
GAIT
He walks across your clinic with absence of heel strike at right sided initial contact, excessive right sided plantar flexion during right mid stance, and poor foot clearance during right swing. There is decreased right sided stance time.
PHYSICAL EXAMINATION
ROM
Lumbar ROM: WNL without Gower’s Maneuver on return from flexion in standing
Hip ROM: WNL
Knee ROM: WNL
Ankle ROM: WNL with the exception of ankle dorsiflexion limited to 10 degrees with the knee extended and flexed.
Limb length:
ASIS to Medial Malleoli: L 31 cm; R 31 cm
NEUROLOGICAL EXAM
Mental status: A&O X 4
Cranial nerves II-XII: normal
Myotomes: 5/5
Dermatomes/Peripheral sensory: Intact to sharp and light touch
Reflexes: symmetrical, 2+; no clonus, toes are down going on Babinski
Coordination: normal finger to nose; heel to shin; and rapid alternating movements
Tone/Spasticity: normal in bilateral extremities
(this is what a normal neuro exam looks like—we will talk more about this next semester in neuro ?)
1) How common is pediatric toe walking? Are there certain groups of children where toe walking is more prevalent? If so, which ones? (10 pts)
2) Based upon the information provided, describe at least 3 conditions can you rule out as the cause of Timmy’s toe walking. Discuss you clinical reasoning with a classmate as to which specific pieces of information you are using to rule out each condition. (hint—use the articles…tables tend to be a good place to find information like this…) (10 points)
3) What information does a clinician gain by assessing passive dorsiflexion with the knee flexed and the knee extended? With the knee flexed, how much dorsiflexion is expected for a child aged 2-8? With the knee flexed, how much dorsiflexion is expected for a young adult? (15 points)
4) You decide that serial casting is appropriate to treat Timmy. What structure are you attempting to stretch? How long does the cast need to be applied? Does Timmy need concurrent botox injections in order for serial casting to be effective? (15points)
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