The goal of treatment is to maintain a foot that is parallel to the ground and perpendicular to the leg.
When to treat ? It is never to early to treat. As soon as the parents recognize the toe walking behavior the child should be bought in for a visit. The problem will not go away by itself. If left alone the child can be left with permanent contractures of their heel cord (achilles tendon) as well they can cause permanent deformity to the ankle joint bones and mortise.
1- Serial Casting- This is a behavior that can be unlearned. In my conversations with pediatric developmental specialists the feeling is that this behavior can be unlearned by the feedback the the cast is performing by forcing the foot down. There is a difference of opinions on what the the length of casting should be.
2- Botox injections with serial casting. This is the preferred method that is used by pediatric orthopedists and myself. I learned this method under Dr John Herzenberg of the International Center for Limb Lengthening in Baltimore. Botox is injected in the muscle belly of the GAstroc- Soleus complex at the nerve roots. Then a below knee cast is applied for a month to 6 weeks. This weakens the muscle and thus allows the child to relearn how to walk properly.
3- Achilles tendon Lengthening- This method id reserved for toe walkers that have not responded to casting. The overall lengthening of tendon weakens the tendon as well as allows it to get the foot parallel to the floor and perpendicular to the leg.
Toe-walking is frequently a behavior displayed by people with autism spectrum disorders (ASD). Several possible explanations have been proposed. Several treatment options have likewise been suggested to address the various theoretical bases for toe-walking.
One popular explanation for toe-walking behavior is that it is a sign of tactile hypersensitivity, which is common with ASD. Since tactile input to the sole of the foot is unpleasant, the person reacts by trying to avoid contact with the walking surface as much as possible. It has been noted that toe-walking is more often observed when the person is barefoot, , in my practice I have seen it equally in shoes and barefoot. Treatment based on this theory is aimed at reducing the sensory hypersensitivity, usually by therapeutic brushing and graded desensitization to tactile input.
A second theory is that toe-walking is an attempt to self-provide proprioceptive input. Proprioception is the unconscious awareness of body position in space, provided by receptors in muscles, tendons, and connective tissue when they are compressed or distracted. Since persons with ASD often have poor awareness of where their body is in space, the theory is that, by contracting the muscles and changing the position of the foot, the body receives extra proprioceptive input. In sensory integration theory, proprioception is also credited with being modulating, calming input, so people who toe-walk when excited may be attempting on an unconscious level to calm themselves. Treatment based on this theory would concentrate on providing the individual with proprioceptive input in other ways, such as jumping on a trampoline, stomping feet, walking in sand, providing traction, and other activities involving compression and traction.
A third theory, proposed by therapeutic optometrists, is that toe-walking is a response to a disordered vestibulo-visual system. It is reported that people with ASD often have adequate focal vision, but very poorly developed ambient vision. (Kaplan, 2006). Ambient vision, which is interrelated with other sensory systems, allows us to see in three dimensions and to correctly perceive movement and distance. Kaplan explains that people with ASD often have either tunnel vision, in which they see only a small arc of visual field, or alternating vision, in which each eye is seeing a separate image. He feels that toe-walking can be explained by tunnel vision, with which persons with ASD “view the world in two dimensions, and cannot accurately judge distance or motion.” Dr. Kaplan reports great success in eliminating toe-walking using prism lenses and a program of vision training.
Sources:
Kaplan OD, Melvin. Visual Management: A Physiological Approach to Rehabilitating Autism Spectrum Disorders. http://www.autism.com/ari/edit orials/ed_visualmanage.htm
