Elsevier

Gait & Posture

Volume 21, Issue 3, April 2005, Pages 311-317
Gait & Posture

The heel-contact gait pattern of habitual toe walkers

https://doi.org/10.1016/j.gaitpost.2004.03.005Get rights and content

Abstract

We used kinematic, kinetic and EMG analysis to compare the spontaneous heel-contact gait patterns of 13 children classified as habitual toe walkers (HTWs) and age-matched controls. In the HTWs, the incidence of spontaneous heel-contact strides during a single recording session ranged from 15% to 92%, with no correlation with age, passive ankle joint excursion, walking speed and trial order. Hallmarks of the heel-contact strides were premature heel-rise, reversal of the second rocker, relative shortening of the loading response and anticipation and enhancement of the electromyographic (EMG) activity normally observed in the triceps surae (TS) during the first half of the stance phase. This variant of the locomotor program is different from the walking patterns observed in normally developing toddlers and children with cerebral palsy (CP). It does not necessarily reflect a functional adaptation to changes in the rheological properties of the muscle–tendon complex.

Introduction

A gait pattern marked by a forefoot or tip-toe weight-bearing attitude during the stance phase of the stride cycle can be observed in children during early independent walking but within a few months this is normally replaced by the typical mature support pattern, the body weight being progressively loaded onto the heel, lateral sole, forefoot and toes [1], [2]. Some children, however, keep walking on their toes, with no clinical signs of sensory-motor impairment or muscular disease, and this is termed idiopathic toe walking [3], [4].

In a small proportion of children toe walking is persistent although they can usually produce a heel-contact gait if asked to do so [5], [6], [7]. A primary increase in the passive stiffness of the calf muscles has been proposed as a cause [5], [8], [9]. In most cases, however, toe walking is facultative and has been described as habitual toe walking (HTW) [10]. In HTW the range of passive ankle dorsiflexion is only slightly limited or even normal [4], [11], [12]. Different etiologies have been suggested for HTW, including clinically undetectable neural impairments and/or anomalous persistence of the immature digitigrade gait, with possible secondary changes in the passive muscle–tendon properties [3], [13], [14].

HTW is not associated with any one single locomotor pattern and its definition largely relies on clinical exclusion criteria [3], [4]. A specific kinematic changes such as increased foot plantar-flexion and reduced knee flexion at touchdown, or greater excursion of the ankle joint angle have been observed in HTW as compared to the equinus gait of children with cerebral palsy (CP) [14], [15]. Similarly, the electromyographic (EMG) profile in HTW, which includes abnormal co-contraction of calf and pretibial muscles in stance and activation of triceps surae (TS) in late swing [16], [17], was also found in diplegic children [18], [19] and even in normally developing children during early independent walking [20]. Several studies, moreover, have reported that the kinematic and EMG features of HTW can be reproduced in normal children, when asked to walk on their toes [10], [15], [21].

Conclusions about the lack of specificity of HTW are based mainly on analysis of selected stride cycles with no consideration for the potentially different gait patterns of individual children. With the exception of a brief mention by Griffin et al. [10], the heel-contact gait of HTWs has never been investigated and so the present study set out to investigate the heel-contact gait in HTW.

Section snippets

Subjects

Thirteen children (mean age 6.6±2.2 years, mean weight 25.5±9 kg, mean height 118±15 cm) participated in the study, with their parents’ informed consent and the approval of the local Ethical Committee. Two children were siblings (numbers 11 and 12). All were referred for gait analysis between 1997 and 2000, and had been diagnosed with HTW by a pediatric neurologist. All had normal muscle tone, deep tendon reflexes, muscle strength and sensation, normal brain and spinal cord imaging, muscle

Results

Within the spectrum of velocity covered in the “walking” and “walking fast” trials (73–130% height/s, mean 97±13%, S.D., 13 subjects), all the HTWs spontaneously adopted both toe/forefoot and heel-contact walking, in variable proportions. The incidence of heel-contact strides ranged from 15% to 92% (Table 1) and was not significantly correlated with the children’s age, passive ankle joint excursion, walking speed or trial order. Within the HTW group, no significant differences were observed in

Incidence of heel-contact walking in HTWs

During any single recording session, the HTWs spontaneously adopted both toe/forefoot and heel-contact gait. The rate of occurrence of the two patterns did not correlate with the children’s age, or the static, passive ankle joint excursion, which ranged from a normal to mildly/moderately-limited dorsiflexion. In our children, therefore, the rheological properties of the plantar-flexor muscle–tendon complex were not likely to be a primary cause of the different locomotor phenotypes. Along the

Conclusions

The heel-contact gait in HTWs appears specific and differs from that seen in age-matched controls, toddlers and from patterns most commonly described in CP. Examination of heel-rise timing, ankle joint angle, VD pattern and spatio-temporal profiles of TSa and TAa EMG components might provide a complementary diagnostic tool for HTWs.

Acknowledgements

This study was supported by Ministry of Education (F.I.R.S.T.) and by the P. and L. Mariani Foundation. The technical assistance of Mauro Recalcati is gratefully acknowledged.

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