Tiptoe
The toe walking (also habitual or idiopathic toe walking ) is a mainly occurring in children transition anomaly in which the toe-goers permanent or situationally of hitherto unknown reasons on the forefoot is. The habitual toe gait represents an expression of the pathological toe gait, which in turn is classified into functional forms, toe gait from orthopedic causes, toe gait from neurogenic cause with spastic- dystonic malfunction, toe gait from neurogenic cause with flaccid-paretic malfunction and toe gait from myogenic cause.
| Classification according to ICD-10 | |
|---|---|
| R26 | Disturbances in gait and mobility |
| R26.8 | Other and unspecified disorders of gait and mobility |
| ICD-10 online (WHO version 2019) | |
distribution
Around 15 percent of all children are affected by habitual toe walking, although it should be noted that this depends on the situation, e.g. B. if you are tired or excited, switch between the forefoot and the plantigrade ("normal") gear. Studies have shown that 64 percent of tiptoe walkers are male and only 36 percent are female. In around 65 percent of tiptoe walkers, the gait anomaly can be observed as soon as they start walking.
root cause
The cause of the habitual toe walking is still not clearly identified. For the most part, it is genetic; in more than half of those affected, a shortening of the calf muscles can be determined.
Disease emergence
The origin of habitual toe walking is unclear. For some children, the first attempts to stand on tiptoe are made. In others, the gait pattern initially develops inconspicuously. An increasing forefoot gait is only noticeable between the ages of 3 and 7 . A congenital muscle shortening in the calves, perceptual processing disorders or a familial disposition are suspected to be the trigger. But none of these theories apply to all tiptoe. New research suggests that certain gene variants are linked to this gait abnormality.
Clinical manifestations
The habitual tiptoe is divided into four types according to its clinical appearance .
Type I affects about 36 percent of tiptoe walkers. The forefoot gait begins when you start walking. Congenital muscle shortening is suspected to be the cause. Characteristic for this type are strong ring folds over the Achilles tendon , a heart-shaped calf and a shortened adductor magnus muscle in the shape of a tennis racket ("T-sign"). The constant incorrect loading of the foot can lead to foot deformities such as a widened forefoot, a pointed heel and a hollow foot even in childhood. About 50 percent of the affected Type I children also develop a hollow back from the age of 2 due to the static statics.
About 52 percent of those affected belong to type II . With this type, at least one family member also walks on the forefoot, so a familial disposition is suspected. The toe walk starts relatively late, mostly between the ages of 4 and 7. Typical characteristics of type II are also a V-shaped Achilles tendon and a heart-shaped calf. Those affected show a forefoot gait around 3/4 of the day and a stomping gait without a rolling phase the rest of the time. Here too, incorrect loading can lead to foot deformities and the development of a hollow back. In this type, the forefoot gait often remains in the form of a teetering gait pattern into adulthood.
Type III occurs in only about 12 percent of those affected. Most of the time, these show a normal gait pattern with a rolling phase. Tip-toe only occurs in certain situations such as excitement, joy, or fatigue. It can also be triggered by certain tests during the clinical examination (e.g. rotation test). In most of these patients, the forefoot will regress on its own and without therapy . There are no deformities of the feet or the lumbar spine within six months of the initial observation . In some patients of type III, perception and attention are also impaired, which suggests a disturbance in perception processing as the cause of the toe-walking.
In type IV , tiptoe walking occurs only on one side, which means that those affected show a limping gait pattern . However, this type is very rare and has the same causes as type II.
Investigation methods
Common methods of tiptoe walking include:
- Family history
- Physical / clinical examination ( visual gait analysis)
- Genetic testing .
pathology
The incorrect loading of the foot and the resulting defective statics of the entire musculoskeletal system can lead to a number of consequential damage. Many of those affected already show foot deformities such as a widened forefoot, pointed heel and hollow foot in childhood. A hollow back can also develop in early childhood. The constant improper stress on the knees and hip joints increases the risk of osteoarthritis . Many sufferers also complain of foot, knee and back pain at a young age . The misalignment of the foot can also lead to a shortening of the calf muscles and the Achilles tendon. One then speaks of an acquired or structural equinus .
treatment
Non-invasive and invasive methods are available for the treatment of habitual toe walking . The non-invasive options include orthopedic aids such as insoles and orthotics , as well as physiotherapy and the so-called serial cast, with which the muscles and ligaments are to be stretched. Invasive methods include administering botulinum toxin to the calf muscle to reduce muscle tension for a period of time. In some cases, surgical Achilles tendon lengthening is all that remains to improve mobility and thus the quality of life of those affected. There are various techniques here, e.g. B. the Achilles tendon extension or the so-called "Z-plasty". Some clinics in Germany now also offer minimally invasive methods.
prevention
The earlier the habitual tiptoe is recognized and treated, the lower the effects and long-term consequences. In the case of a known family disposition, it is therefore advisable to carry out an early diagnosis before the child starts running .
Prospect of healing
Complete healing of the tiptoe is not possible. However, it is possible to treat the symptoms and minimize consequential damage. About 70 percent of those affected can learn to walk normally through conditioning . In a therapy study from 2018, conservative therapy with pyramid insoles, mostly supported by physiotherapy, proved to be very successful for this conditioning . Of 193 children with tiptoe, around 90 percent were successfully treated.
history
Already in the antiquity of toe-walking has been observed. This gait anomaly was already mentioned by the Greek physician Hippocrates of Kos (approx. 460-370 BC), the Roman writer Aulus Cornelius Celsus (approx. 25 BC - 50 AD) and in the lexicographical reference work of Marcus Verrius Flaccus (approx. 55 BC - 20 AD) prove this. There is much to suggest that the epithet "Atta" used in antiquity denotes a tip-toe. A well-known bearer of this name is the poet Titus Quintius Atta , who lived around 77 BC. Should have died.
Problems in everyday life
In everyday life, the toe walker is confronted with an abundance of problems of a physical and psychological nature . The most important are:
Physical disabilities
- lower endurance and strength
- poor mobility
- decreased ability to maintain balance
- Difficulty walking / frequent falls
Psychological aspects
- Problems integrating
- Teasing by their peers
literature
- R Korinthenberg: Differential diagnosis of the toe gait in: Neuropädiatrie in Klinik und Praxis, 2002 [2]
- David Pomarino et al. (Ed.): The habitual tiptoe. Diagnostics, classification, therapy. Schattauer, Stuttgart 2012, ISBN 3-7945-2851-4 .
- David Pomarino et al. (Ed.): Toe-walking. A parenting guide . OmniMed Verlagsgesellschaft, Hamburg 2018, ISBN 978-3-931766-37-5 .
Web links
- Pomarino's disease , MedLexi.de
Individual evidence
- ↑ D Pomarino et al. (Ed.): The habitual tiptoe. Diagnostics, classification, therapy. Stuttgart 2012, p. 1, 12 .
- ^ R Korinthenberg: differential diagnosis of the toe gait. In: F Aksu et al. (Ed.): Neuropädiatrie . Bremen 2011, p. 379-385 .
- ↑ D Pomarino, J. Ramírez Llamas, A Pomarino: Idiopathic Toe Walking. Family Predisposition and Gender Distribution. In: Foot Ankle Spec . tape 9 , no. 5 , 2016, p. 417-422 .
- ↑ D. Pomarino, A Thren, S. Morigeau, J Thren: The Genetic Causes of Toe Walking Children. In: Genet Mol Biol Res . tape 2 , no. 2 , 2018, p. 9 .
- ^ K Radtke, A Thren et al .: Outcomes of Noninvasively Treated Idiopathic Toe Walkers. In: Foot Ankle Spec . tape 11 , no. 2 , 2018, p. 1-8 .
- ↑ Markus Stachon: Atta is not a name, but a diagnosis! On the cognomen of the poet T. Quintius Atta (Paul. Fest. P. 11, 17-19 L.). In: Glotta . tape 95 , 2019, pp. 310-319 . [1]
