Toe-Walking

Is toe-walking something we outgrow? These are some of the questions answered in today's podcast with Liesa Ritchie PT, DPT, PCS from ⁠Know To Change⁠ for both parents and health providers alike.

Edited Transcript

Marsh Naidoo (00:12):

Welcome to this episode of the Raising Kellan Podcast. My name is Marsh Naidoo and I blog at www.raisingkellan.org where we curate resources for parents raising children with developmental delays and disabilities. As always, remember, the content on this podcast is purely informational, and if you seek advice for your specific situation contact a trained professional. Today's episode is brought to you by Move Up Physical Therapy, a private practice in Bartlesville, Oklahoma, owned and operated by Rebecca Renfro. In today's episode, we chat with Liesa Richie, who is a physical therapist and expert in toe walking. So for those of you parents out there wanting to know more about this topic, this would be a great resource. So grab that cup of coffee, put your feet up, and get ready for some awesome conversation. Liesa, I would like to welcome you to the Raising Kellan Podcast. We are so happy and honored to have you here.

(01:32):

Thank you for asking me <laugh>.

(01:35):

Liesa guys, as you've already heard, is an expert in toe walking, and I am just excited to be talking to her to shed light more on this area. Lisa, before we head into toe walking, can I ask you, if you don't mind, to share a little bit about your background? Some of your history as a pediatric therapist, which I found fascinating when I read about it, and more about your career as well.

Liesa Ritchie (02:12):

Of course. Well, first of all, I'm flattered that you call me an expert. That's not a word that I use for myself. I just think that I have done a tremendous amount of toe walking <laugh> with a lot of kids, and I've just figured out some things along the way. So and that's kind of how I would see it. So starting out, it's funny as far as my history as a therapist, I don't have kids myself. I chose not to have kids myself. People who know me know I'm not really the biggest fan of children and so <laugh>. And so when I got my first job in pediatrics, my friend said to me, did they do background checks there?

(02:58):

That was, that was about 30 years ago. I wanted to go into hand therapy and I'd had that job for a year, and then I was, I was laid off. And so I took a job in pediatrics, literally just until something better came along. That was my plan. And that was 31 years ago. I've been working in pediatrics 31 years, and I love it. I love it. Maybe still not the biggest fan of kids in restaurants, but Kids in the Clinic, I love 'em. It's a whole different population than the kids in restaurants.

Marsh Naidoo (03:27):

<Laugh>, you know what, it, it's so crazy how that works and because prior to me having Kellan, never in a million years that I ever think that pediatrics would be a field that I would kind of be interested in <laugh>, it's, I've always, I love my, my geriatric patients. So it is so strange how that, it's like God has a wonderful sense of humor

Liesa Ritchie (03:51):

Sometimes <laugh>, I think. I mean, I do, yeah, God clearly knows, you know, no, Lisa, I got some plans for you, and it's not in the hand arena. You gotta go here. And I do. I love it. I, for me, I, I think what I like about the pediatric part is it's, you are not just seeing one person, one body, one thing. It, it does encompass the entire family and, and their lives. And so that I think is where it really met the need for me that I, you know, as you know, we don't just work with the kid, we work with the whole family. And, and I also love what you can do with kids' bodies as far as improving their function. You know, you do it as an adult and, we're kind of, we're maybe setting our ways mentally, but we're also set in our ways physically. But for the kids, their bodies are still so plastic. They're still so easy to better, better able, I should say, maybe not easy, but better able to make changes. And so that's, I think that's one of the reasons I've stayed in pediatrics for, for so long. And then pediatric therapists are just a different group of people, and I really like that. They're my people for sure. <Laugh>.

Marsh Naidoo (04:57):

Now, Lisa, you, you not in clinical practice right now? Tell us about your work right now as it stands.

Liesa Ritchie (05:06):

Yeah. So I did the, you know, the traditional outpatient clinic for a good 20 years. And again, unloved it went, was a staff, therapist, was management, the, the whole thing. And I opened up a few clinics too, so adult-based clinics would want to open a pediatric program. So I would, I would do that a and m. So I did the traditional stuff for a while and then but then as I was traveling and teaching the toe walking courses, it just exploded. I mean, it just took a good 50% of my time. So in order to continue doing that, I had to do less of the clinical practice. And then it got to where the clinic was running, just, just fine without me unless, and until they got the really complicated cases.

(05:54):

So I'd go in with the difficult ones, <laugh> you, which is a double-edged sword really. Cause it keeps your mind going and it keeps you thinking, but we're also seeing challenging cases. And so that was so I did that and, and still do. But then again, the teaching just got, just got real big. And then Covid moved everything to a webinar for a while, and that just seemed to meet a need. I could still continue teaching through webinars, but without the case, the crazy and the chaos of being on a plane every three, or four days because that gets, that gets tiring. So I forget what your original question was, but Yes. Traditional stuff. That's right. You asked me about teaching and the teaching just really fits my life at the moment, and I can reach more people that way. I taught almost 30 people in Malta, right? I taught over a hundred in the UK for their national association. I do a lot for Australia and New Zealand, and so I can kind of, I've traveled to those places, which is great. But the webinars, I think it makes them more accessible to me and me more accessible to them. So it, it works for now.

Marsh Naidoo (07:08):

So tell us about Know to Change. I think those pediatric therapists listening would be curious to know how they could learn more about treatment options available to those clients who toe walk. So can you tell us a little bit about Know to Change?

Liesa Ritchie (07:28):

Yeah, so then the name actually came from exactly what they wanted to do. We were working with the toe walkers and we were seeing an, there's an increased number of children diagnosed with this term, idiopathic toe walking. And I found that several disciplines, you know, PT, OT, speech, we were just throwing a bunch of stuff at these kids and some things would stick and some things wouldn't. And a lot of what we were taught was not effective. A lot of what we were taught was just not working. And so I felt that was strong, that's where the name came from, was we need to know as it's in knowledge, it's not, no, it does not say "no to change", it's K N O W. And so we needed to know to change when what we were doing was not effective.

(08:14):

And so that's where that came from. And then like I say, we were just a lot of disciplines with no real, real order and no real design and specificity with what we were, we were doing. And so, again, it's kind of twofold, really. I like I say, I teach the approach, how to address the toe, walking from a slightly different perspective. Well,a lot different perspective actually than what we're taught. And then the other part of it's, I tend to put people together. So I'll have parents contact me and say, Hey, I'm looking for somebody in whatever in the Chicago area, you know, I need a therapist or I need an orthotist, and I can, I have a pretty big reach so I can put that out and people can find each other. And then I, and I also have a subscriber list, so I'll send that out and, and an email, Hey, looking for a therapist in the Chicago area. So, but the education, and I'm kind of a conduit for people as well if you will.

Marsh Naidoo (09:13):

A connector. Yes, absolutely. So Liesa a mom or a dad, like observes their little one toe walking, they address this issue with the pediatrician and they're told, you know what, it's just fine. It's something they would grow out of. What would be your advice to the parent that kind of gets this kind of feedback?

Liesa Ritchie (09:43):

Think it's, I mean, it definitely does happen. I hear reports from parents and therapists, like the toe walking, you know, eventually did resolve. So I do hear that it's not unheard of, but what I find is the dysfunction that happens early on as a result of that abnormal movement pattern that dysfunction continues on. So, okay, great, you had to put their heels down, okay, but we see pain, he hip pain, knee pain, back pain, that kind of thing. We also see poor-quality movement later on. And so maybe sports are difficult or maybe they fall with regularity. We see footwear is a challenge, and so the, I guess my response to, let's see if they outgrow it, is what if they don't? Yeah. Because now we've got those things, to deal with. So I really try to address it from a very proactive approach.

(10:41):

If they outgrow it and I was wrong, I was wrong, but what if I wasn't? And we could have made it, we could have made a big difference. And then the timing is, is very important as well, because there are certain stages of development where it's easier to make change and it's more difficult afterward. So with the development of the foot when we're talking about the skeletal system, the potential for change of the foot development, the potential for change is a lot less after six years of age. So that's why I try to be proactive. Changing a gait pattern, the potential for change is less after about seven years of age, on balance, the potential for change is less after three years of age. So it doesn't mean that we can't make those changes, you know, oh, your child's eight years old, it's too late, I can't help you.

(11:27):

It's not that, but we can be of more benefit earlier on. So that's why I try to be, like I said, a little more proactive. And then on the website, I actually I do have something that's, that's downloadable where parents can look and, and it kind of, it describes when toe walking may be of concern and when it may not be of concern and it gives specific things to look for. But ideally, when we look at normal ideal gait development, when we look at the research behind it walking on toes is actually not a part of ideal development. We really don't have any studies that support that I think it's seen. I think there are stages of development where a child might go on their toes, Planter flex for a couple of steps, but it's very short-lived. When we look at the research that describes normal ideal gait development kiddos really should have heal contact about six months after independent gait. That's ideal development. So six months after they start walking by themselves, they should have heel contact, and then by about three years of age, then we should see that traditional heel, toe, heel toe, heel, toe. So those are just some things to kind of keep in mind.

Marsh Naidoo (12:43):

Leisa, I definitely wanted to kind of tap your brain as far as possible treatment options, but that might not really make sense if we kind of don't touch on what are the possible causes or factors that contribute to toe walking, like before we hit into possible treatment.

Liesa Ritchie (13:07):

Yeah,I think, yeah, and I think you're right. Let's kind of look at the cause first because what we're taught traditionally both in school and then in some, you know, post-continuing education, what we're taught traditionally is the approach of stop the toe walking. And, and we go about that a variety of ways, which we can, which we can get to. But for me, movement happens and begins in the brain. And so for me, I don't address the foot. I mean, I, I look at the alignment, but I really address it from an etiological perspective. And based on where the etiology is, how is the toe walking meeting a need, if we can then tailor our interventions towards addressing that need, like what's the toe walking meeting? Okay, how can we meet that differently and not have the same kind of orthopedic and movement problems later on?

(14:03):

So the, yeah, the causes do vary depending on the, on the kiddo and it can be, it can be toe walking where we kind of know where we know that it'scerebral palsy or something like that. But then also where we're not quite sure they go in that idiopathic category, which is kind of where I hang out. And then, okay, what is it? Is it a sensory etiology? Is it a musculoskeletal one? Is it a neuromotor? And I don't mean neurological, it's different, but like neuromotor, is it a map that's in the brain because whether it's, depending on what it, where it's coming from, governs how we address it.

Marsh Naidoo (14:42):

And then so mean, possible treatment options for parents that might wanna seek early intervention or intervention period for their children. What are perhaps some treatment options that they could look into?

Liesa Ritchie (15:04):

Yeah, I think that how can I start with this? So treatment options that are, that are available, they're, and there's nothing necessarily wrong with those. We have the, we have the traditional, we have the physical therapy to help retrain the movement pattern. We've got orthotics, we've got Botox we do op, there is definitely surgery. So those options are out there and they're pretty, I mean, a Google search will reveal that they're pretty well known. However, I just can't get away from it, is that we don't do the same thing for every kid because their walking pattern is different. And the reason why they're doing that is different. So we, within all of those interventions, I guess what I would say is it needs to be specific to that individual child. So rather than this is the brace we do for tow walkers, it would be what type of orthotic is gonna promote better alignment for this particular child based on the way that they present

Marsh Naidoo (16:11):

Is there anything else that you think we need to touch on as far as kids that present with a toe-walking gait?

Liesa Ritchie (16:21):

Yes. <Laugh>, I've got about 20 hours on it. Do, I can summarize it for you. I think when we're looking at a, from a, from a parent's perspective, like should I be concerned, should I not? Again, I would look at the I would, I would seek advice if they've been if they've been walking for six months by themselves and they are still on their toes, then I'd say, I mean, really much less than a third of the time, it really shouldn't be there at all. And so I think that's an area where we know from, as I say from normal development, that that's not optimum. So we would look for that. There are a couple of groups that are predisposed to different movement patterns. Premature babies are for a variety of reasons. Kiddos who've had some kind of GI issues, history, so colic, reflux, constipation, those guys tend to have a seem to be a little more, a little more represented in the toe walking population, you know, when I dig into their history.

(17:28):

So GI, preemie, and then lower birth weight too and, and that, so those would be, I'm not saying that if you have any of those three situations, your child will be a toe walker, but if they have those situations and they're walking on their toes, again, I would kind of go with more of the proactive approach. Other things to look for is if they dislike their feet being touched, if clothing tags bother them, and maybe they don't like getting their hair brushed, those things might be worth looking into from a sensory-responsive perspective. Car sickness also, kiddos should really not be car sick much beyond age three. So that might be a vestibular you know, concern. Oh, speech, there's a correlation. It's not caused and effect, but there is a correlation between speech delay and, and toe walking. So it's more, if they have a cluster of things, then we might wanna dig, dig a little deeper. Yeah, so it's, that's kind of where I'd go with that I think

Marsh Naidoo (18:35):

For therapists wanting to know more about, how they could address this particular, patient population, and want to find out more about the research and you know, kind of get more hands-on training. Lisa, what resources are out there?

Liesa Ritchie (18:58):

Yeah, and this is a tricky one cuz like I said, I'm not overly traditional. And so the research is difficult. The research is, is oriented that's out there, is oriented towards a lot of Botox and surgery, which I personally have not found to be overly successful. I like to look at that as more of a last resort as opposed to a first resort. So the research I always say that a lack of research doesn't mean an absence of evidence. I have a lot of evidence that absolutely my approach works and it's effective. There's a lot of evidence that we see the before and the after and the kids don't come back. So there's a lot of evidence, but it's not, it's necessarily supported in the research. And then with regards to therapists getting hands-on-again, there are definitely ways that I can connect people, you know, I can, hey, and I did that.

(19:56):

It's something that I don't know happens very often cuz I think once we get outta school we're like, oh my gosh, I've done my clinicals, I'm overwhelmed. But for me, in the very beginning of my career, I spent a huge amount of time watching a therapist. So, you know, on my own time I would ask, Hey, OTs, can I sit with you and learn about what you do for sensory integration? Spent time watching other clinicians and observing them. And everybody's not in the position to do that. But if I were to connect you with someone who's effective at treating toe walking in your area, if you could go spend some time with them, that would be a way to invest in your career. And it's rewarding because it's, there's nothing more frustrating than us doing something and feeling that we're not being effective.

(20:38):

So I think it's worth putting the time upfront. And then of course, you know, I have a variety of different webinars. I've got the real short intro ones that are about an hour and they really just give an insight into my philosophy. But the actual hands-on training you don't really get with the webinar. But I haven't found that to be a big barrier. When I went from the shift of in-person to webinars, I haven't really hasn't been an issue. People are still contacting me afterward like, I've been doing this, it's really effective, that kind of a thing. But I have the more lengthy webinars as well.

Marsh Naidoo (21:18):

Liesa, thank you so much for joining us. Would you kindly mind giving us that website?

Liesa Ritchie (21:24):

Absolutely. It's knowToChange.com and as I say, the KNOW is in KNOWledge.

Marsh Naidoo (21:38):

Thank you so much for listening along on the podcast today. Kindly leave us a rate and review on your podcast platform that would be highly appreciated, as well as share this episode with friends and family who may be seeking the information. Until we see you guys the next time, as always, remember, get to the top of your mountain. This is Marsh Naidoo signing off.