Slozhenikin Evgeniy Valentinovich
Pediatric neurologist. Author of the blog on Instagram @doc_slozhenikin. Her work is guided by the principles of evidence-based medicine.
Introduction
It's a joy for any parent when their child begins to walk independently, but bad luck... he walks on his toes. Indeed, WALKING ON THE TOES is a very relevant and frequent question for discussion at an appointment with a pediatric neurologist.
The criterion for this condition is the absence of contact of the heel with the surface of the support throughout the entire support phase of the step cycle, or early lift-off of the heel at the end of this phase. ⠀ Episodes of walking on toes occur in most children who begin to take their first steps. This walking pattern does not always, but most often goes away spontaneously within 3-6 months after the start of learning to walk independently.
Children who continue to walk on their toes even after they have reached the age of 1.5 - 2 years old usually do so out of habit. If the child’s growth and development are normal, then independent toe walking is not a cause for concern.
Let's look at a few reasons why a child may persist in tiptoeing.
Injuries
Sports and outdoor games are good for health and physical development, but they often cause injuries and foot pain in a child.
These include:
- Bruise or closed tissue damage. Occurs during a fall, impact, or collision. Causes swelling, hematoma (bruise);
- Ankle sprain. Occurs when the foot accidentally rolls inward while running, quickly descending stairs, or walking. Causes acute pain that gradually decreases, swelling on the outside of the ankle joint, and difficulty supporting the leg.
In case of injury, you need to apply cold to the affected area and provide it with rest. Be sure to consult a traumatologist to find out the severity of the injuries. If you suspect a dislocation or fracture, call an ambulance immediately. Before she arrives, immobilize the injured limb.
Muscular dystrophy
Muscular dystrophy is a genetic disease in which muscle fibers become very susceptible to damage, causing them to become weak and wasted. This is due to a disruption of a protein called dystrophin, which helps maintain proper muscle function. The incidence of Duchenne muscular dystrophy among newborn boys is 1 case in 3,300; Becker muscular dystrophy is 6–10 times less common: 1 case in 18,000–31,000.
Such children begin to walk late, they often fall when trying to run, they have difficulty jumping, due to weakness of the proximal muscles they have difficulty climbing steps, stairs or on an inclined floor, and due to contracture of the tendons of the foot they walk on their big toes. Characterized by increasing pseudohypertrophy of the calf muscles.
Sever's disease
Sever's disease is an inflammation of the growth plate of the heel bone. Occurs in children aged 9 to 14 years. Unlike adults, the heel bone in children consists of two parts connected by a cartilaginous layer (growth zone). Cartilage tissue is weaker and at greater risk of injury than bone tissue. If due to excessive tension it becomes irritated or swollen, this causes pain that children feel around the perimeter of the heels.
With Sever's disease, the child's feet hurt after training or intense physical activity. At risk are children involved in football, basketball, athletics, running, and jumping.
To make your child feel better, apply cold to the place of pain and provide rest to the leg. See your doctor. He will prescribe orthopedic insoles and special inserts that will reduce the load on the heel. He will tell you what you can and cannot do. In severe cases, the foot is temporarily fixed with a bandage.
You are allowed to return to sports after 2–3 months. It is important to take precautions to prevent the problem from recurring. Choose comfortable shoes with soft soles for sports, and stretch before and after exercise.
Cerebral palsy
Cerebral palsy is a concept that unites a group of movement disorders that arise as a result of damage to various brain structures in the perinatal period (from the 22nd full week of intrauterine life of the fetus to the 7th day of life of the newborn child). These structures are responsible for controlling motor functions, muscle tone, coordination and posture.
In spastic cerebral palsy, the muscles around the feet are known to become very stiff, which can make walking difficult. Some premature babies may also suffer from bleeding in the brain, which can cause cerebral palsy and lead to problems walking, which promotes walking on their toes.
Flat feet
If the cause is flat feet, then the child’s feet often hurt after physical exertion, standing for a long time or walking for a long time. The pain can spread to the ankle joint, shins, and reach the knees.
Parents may not know for a long time that their child has flat feet, or may not attach much importance to it. But this is a mistake, since it affects the health of the entire musculoskeletal system, causes improper distribution of body weight, and increases the load on overlying joints and the spine.
Flat feet happen:
- flexible, when in a standing position the foot is flat, and when rising on the toes or raising the big toe upward, the arch (bend) becomes noticeable. This type of flatfoot does not cause any discomfort and goes away on its own after 3 years;
- hard, when the arch is not visible in any position of the foot. To correct the shape of the arch, special shoes or orthopedic insoles are prescribed, as well as gymnastics to strengthen the muscles.
Autism spectrum disorder
Autism is a clinically diverse group of psychological developmental disorders characterized by qualitative abnormalities in social interaction and communication patterns, as well as a limited, stereotyped, repetitive set of interests and activities. In addition to these specific diagnostic signs, a number of other nonspecific problems are often encountered, such as phobias, sleep and eating disorders, aggression and self-aggression, which should be identified as conditions accompanying ASD. This disease is detected already at the age of 1.5-2 years, when the child must actively talk and explore the world around him. Research shows that among children with autism, up to 41% can walk on their toes.
Bumps on the feet
This is what parents call convex formations and compactions: corns, calluses, warts, consequences of injuries. They can really be a nuisance. If a child has such a bump on his foot, it hurts to step on his foot.
You shouldn’t find out on your own what kind of lump it is or use folk remedies. You need to consult a specialist. He will find out the nature, the cause of formation, and prescribe treatment. The bump can be associated with uncomfortable shoes, heavy load on the feet, foot deformation and other factors.
Sometimes children develop a hygroma - this is a hard bulge near the ankle joint, a capsule with a dense wall and a jelly-like mass inside. Hygroma looks like a lump or bone on a child's foot. It hurts if it compresses the nerve endings, becomes inflamed, or makes it difficult to move in the joint.
Forecast, conclusions and main provisions
- Walking on toes without other clinical manifestations in children under two years of age is normal and does not require treatment.
- Idiopathic toe walking is a diagnosis of exclusion. Differential diagnosis with a large number of diseases is required.
- In most cases, treatment is not necessary. Observation.
- None of the existing treatment methods gives a predictable result.
- Exercises, insoles, splints, plaster or botulinum toxin - the choice is up to the doctor and parents.
Don't forget that serious diagnoses always have many other symptoms besides toe walking, so they are unlikely to be missed.
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Plantar fasciitis
This is the name for inflammation of the plantar fascia, a thick strip of connective tissue that runs along the bottom surface of the foot. It connects the heel bone to the bones of the forefoot and supports the longitudinal arch. Plantar fasciitis is caused by flat feet, a sharp increase in physical activity, running, jumping, and excess weight.
The child complains of pain in the foot in the heel area in the morning when he takes his first steps. With difficulty he steps on his foot after getting out of bed. After it disperses, the pain decreases or disappears, and the next morning it appears again.
Rest, cold, anti-inflammatory drugs, exercise therapy, massage, orthopedic shoes help. It is necessary to temporarily exclude running, jumping, and long walking. Treatment is prescribed by a doctor.
Achillodynia
This pathology is associated with the development of an inflammatory process in the Achilles tendon, which connects the ankle and heel bone. The causes of inflammation are:
- pathogenic microflora that penetrates the tendon in the presence of an inflammatory process in the body that occurs in a chronic form (gonorrhea, rheumatism, tuberculosis);
- joint injury;
- strong physical activity, especially when running and jumping in place;
- wearing compressive and rubbing shoes.
Type of pain The pain is aching, accompanied by an increase in temperature in the ankle area.
When walking, there is tingling, cramps, and coldness in the calf muscles.
Localization of the ankle. Diagnostics The diagnosis is made based on the results of laboratory tests of biomaterial: urine, blood and puncture of synovial fluid. The diagnosis is supported by ultrasound data, which can reveal the presence of inflammation in the Achilles tendon. Treatment If the cause of inflammation is infection, antibiotics and NSAIDs are used in treatment to help overcome it with minimal losses to the body. Further treatment involves the use of physiotherapeutic procedures such as:
- magnetic therapy;
- UHF;
- electrophoresis;
- shock wave therapy.
The patient needs to reduce physical activity, giving the leg as much rest as possible from stress.
It is recommended to go to the pool, massage the ankle, and also perform simple exercises to increase blood flow to the affected area of the leg.
If there is an advanced stage, an operation is indicated in which the mucous bursa is excised through a small incision in the tendon. The rehabilitation process in this case can take 1-2 months.
Achilles tendonitis
Tendinitis or inflammation of the Achilles tendon occurs due to sudden increased physical activity of the child, pressure on the heel, back of the foot, during intense sports activities.
Symptoms include swelling, redness, and difficulty walking. It hurts the child to step on his foot. Treatment includes rest, cold, fixation of the foot with an elastic bandage or a special bandage to support and reduce the load on the tendon, and elevated position of the leg. For severe pain, anti-inflammatory drugs are prescribed.
Overweight
The foot can withstand not only body weight, but also loads in excess of normal . However, when the weight constantly increases, the tendons are constantly in a stretched position, in which their anatomical ability to return to their original size is lost.
Therefore, children who are obese may complain of painful heels more often than those who are not aware of such problems.
Type of pain Aching, nagging pain in the heel, radiating to the ankle. Appears after long hikes or physical exertion. Localization: Ankle and heel. Diagnosis Excess weight is one of the root causes of heel pain, but it is necessary to take an x-ray to exclude the possibility of developing more serious foot pathologies. Treatment The little patient is examined completely, trying to determine the true cause of uncontrolled weight gain.
After the weight returns to normal, the pain stops bothering me.
What to do?
First of all, you need to find out the reason why your child’s foot hurts. Were there any skin lesions or injuries, what did you do in recent days, how did your activity change, did you wear new shoes? These questions will help you navigate. If the pain does not disappear within several days and prevents you from walking normally, be sure to consult a doctor.
This could be a pediatric surgeon, traumatologist, or orthopedist. Tell us all the symptoms, when the pain first appeared, whether there are difficulties when walking, where the child’s foot hurts (in the middle, in the heel or toes), what other complaints.
Be sure to see a doctor if, in addition to foot pain, your child has:
- temperature;
- redness;
- signs of infection, purulent discharge;
- tingling, numbness;
- changes in the normal position of the foot;
- loss of stability when supporting the leg.
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In what case should you see a doctor immediately?
The child's body reacts extremely critically to pain, so any complaints should be taken seriously. Medical assistance is urgently needed in situations such as:
- the child cannot step on his heel, which is accompanied by acute pain and the development of hysterics;
- the calcaneal tubercle is deformed and protrudes noticeably beyond the rear arch of the foot;
- body temperature rises;
- the area of the ankle and heel swells and acquires an uncharacteristic shade of the skin.
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Fortunately, inherited and acquired foot defects can be corrected. With the help of special rehabilitation measures, it is possible to stop the disease and prevent it from developing into a more severe form. Depending on the child’s age, his development, and the nature of the flattening of the foot, the doctor will prescribe a massage and a special set of exercises that need to be performed at home. If your child does gymnastics diligently, positive results will soon make themselves felt: the arch of the foot will become significantly stronger, take on an arched shape, and the displaced heel will take its usual place.
Daily warm (35–36°C) foot baths, leg and foot massage (rubbing, stroking and kneading) will be good allies. These procedures improve blood circulation and tone the muscles that lift the arch of the foot. Massage the inner surface of the shin in the direction from the ankle to the knee, and the feet from the toes to the heel.
In addition, the specialist will help you choose orthopedic shoes or recommend making individual corrective devices (orthopedic insoles) with arch alignment and raising the inner or outer edge of the heel. The insoles create comfortable conditions for deformed feet; they can be worn from the age of two after consultation with an orthopedic doctor. Do not forget to periodically see a doctor for timely correction of the height of the instep supports. Insoles should be included in both outdoor and indoor shoes.
You should not choose orthopedic shoes on your own: even a small mistake can aggravate the problem.
It is important to remember that all methods of conservative treatment end by the age of 10, when the processes of formation of the physiological arches of the foot are completed and only surgical intervention is possible.
Stores sell many different devices (special mats, cushions, balls) for doing gymnastics and self-massage at home. Exercises help improve blood circulation and normalize muscle tone.