The Power of the Calves

I don’t know about you, but I have had many children over the years that really struggle to use their calf muscles in an efficient and effective way. This could be due to many reasons but there is probably some underlying weakness and coordination challenges. I have seen this a lot in my kids who are toe walkers. Now I’m sure some of you are saying ‘wait but they walk on their toes, doesn’t that mean they use their calf muscles and they should be nice and strong?’

Not necessarily. Because they tend to walk on their toes (this may look like they are up high on their tip toes or it may look like a shuffling walk with the foot mostly flat but never getting a heel strike first) they aren’t moving through the full range of motion at their ankles and so their calves are only working in a very small range. For the kids up on their tip toes they are really strong in that one position but they would fatigue pretty quickly if you were to ask them to do multiple heel raises in a row. For kids whose feet look flatter but they are still not hitting with their heels first, they are tending to constantly stop a ‘fall’ forward by catching themselves on their foot and then ‘falling’ forward onto the next foot. They aren’t using their calves to help them push off to lead into the step, but rather ‘falling’ into the step.

So as you can see calves work in two ways, they help to control your step forward by supporting your body weight as the muscle slowly lengthens, and they also help to push off by shortening the muscle to give you power to go into the next step. These are also helpful for jumping and running activities to name a few.

Hopefully all this is making sense. I really started this post to give you some ideas for how to work on the calf muscle to help your kiddos use them more effectively and efficiently!

• Scooter Board Push – I was inspired when I came across this post. I have a few kids that I have been trying to get creative on ways to work on their calves. I actually tried this one out and the kiddo I was working with loved it! He loves to do puzzles so we put the puzzle pieces on one side of the room and were assembling it on the other side of the room so he had to push me back and forth to get all the pieces. Because of the size of the room we had some extra challenges because he had to turn a corner as well causing him to work on his motor planning. In the beginning he had some trouble and would try to go down on his knees to push or I would help him too much so he was just walking and not pushing through his feet but he eventually got it and was so excited when we would get going fast and when we could turn the corner without running into the crash pad! I completely recommend this activity. Just an FYI, carpet causes them to work harder!
• Wall Push Offs – You can do this one on a scooter or a swing. With a scooter you can have competitions to see how far you can push each time and if you can get further than your last time. Or you can set up bowling pins that when they push off the wall they have to try to knock them over and see how many tries it takes before they’ve knocked them all over. You could also use an exercise ball and have them push off of that and see how many pushes it takes to get down the hallway, and then try to get fewer pushes on the way back! Obviously you would have to move the exercise ball to them each time and hold it stable while they push.
• Furniture Gliders – With the smooth side down on the furniture gliders, have them put their hands on the top side. Then create a course with painters tape and have them push their hands all along the path. The key is to make sure they are pushing with their feet and not dropping down onto their knees. You can change up the course and make it straight lines, curved lines, zig zag lines, or have it be a treasure hunt/maze where they have to follow the lines to get to bean bags or puzzle pieces and then they bring them out of the maze before going back in to collect the next one! If you don’t have furniture gliders you could do this with bear walking but its definitely more fun with being able to push yourself around! You could also try putting their hands on a scooter and pushing that way if you don’t have furniture gliders!
• Step Downs – Stepping down slowly really helps to work on having the calves control the body weight as it lowers down. That being said, this is often hard for kids to control. We have tried putting a stomp rocket on the ground below the step so they have to step onto the stomp rocket to get it to go. If possible I recommend doing this without rails. You can change the height of the step to make it easier or harder. And the kids love to shoot the stomp rocket. We generally have targets that we aim for. You can give points to each target and have them try to get a certain number of points by hitting them with the rocket.

What are some ideas you have for calf strengthening with kids?

Toe Walking Revisited

I had written a post on toe walking a while back and since then I have learned some new things so I thought I would expand on what I had written.  I recently went to the APTA combined sections meeting in Chicago and took this great session on idiopathic toe walking (when the toe walking can’t be attributed to any other diagnosis or condition).  Here is some of what I learned:

• Doctor’s often don’t refer soon enough because they think the kids will ‘grow out of it’
• No where in the literature does it describe toe walking as ‘normal’
• Usually heel strike (meaning the heel hits the ground first unlike toe walking where its the front of the foot or a flat foot) occurs at 22 weeks after independent walking and should definitely be there 50 weeks after independent toe walking
• When we walk we have 3 ‘rockers’.  The first is when our foot hits the ground, the second is when our leg advances over our foot and the 3rd is when we push off.  Kids who are toe walkers almost never develop the 2nd rocker phase even if their heels drop down to the floor.
• Often what looks like the kids coming down off their toes is that weight is helping them push their heels down onto the floor.
• Without the second rocker phase they aren’t getting the normal loading of weight through the foot.  They can often develop a wide forefoot because they are putting more weight through that part of their foot.
• They will usually over use their big toe extensors to clear their foot during walking because the muscle (anterior tibialis) that helps them to lift their whole foot doesn’t work as efficiently
• As a result of toe walking these kids will usually have tight calves.  What’s interesting is that one study showed that if the kids got the range of motion back in their ankles, the timing of their ankle muscles improved and they were better able to use the muscles (anterior tibialis) that lifts their foot up
• In addition kids who are toe walkers often have weakness of their hip extensors (butt muscles).
• You will also see core weakness with these kids as well as trouble with standing on one leg and hopping on one foot.
• Another thing you will notice with kids who are toe walkers is that they don’t play in squatting with their feet flat on the floor
• Just because a kiddo can walk heel to toe when you are cuing them doesn’t mean that they have stopped toe walking.  We want them to do it automatically because how realistic is it for you to walk around telling them heel to toe every day, all day.

What does all this mean?  Well, if you have a kiddo that is a toe walker I would recommend having your doctor get you a referral for physical therapy sooner rather than later so that the PT can give you exercises to work on your child with so that they can develop a ‘normalized’ walking pattern which will help them as they continue to grow with running, walking, jumping, etc more efficiently.  For kids who are older (usually once they are older than 3) they will often have tighter muscles and may need some additional support to help them with their walking.  This can often look like serial casting to increase their ankle range of motion or a DAFO #9 for a night splint or using a hinged AFO (ankle foot orthosis), like the DAFO #2, that allows them to bend at the ankle but not to come up on their toes.

My biggest recommendation would be to get a consult with a pediatric physical therapist so you can find out if you should be concerned or not.  Usually its not a big deal but as with everything its a lot easier to change habits and motor patterns the earlier they are addressed.

I hope this was helpful!  If your PT has questions about what to do for idiopathic toe walking they can go to the clinical guidelines for toe walking developed by Cincinnati Children’s Hospital Medical Center on the National Guideline Clearinghouse.

Toe Walking: Is it a Big Deal?

What is toe walking?  Toe walking in kids is when they either drastically walk on their tip toes or they don’t hit the ground with their heel first.  Walking is broken up into two phases, swing phase (when your foot is off the ground) and stance phase (when your foot is on the ground).  Toe walking would be noticed in stance phase because when their foot should be flat on the ground, it isn’t!

Walking develops with the child and when they first start walking they hit the floor with their foot flat and don’t rely on their calves and ankles much for walking.  As they develop a more mature gait (usually between 3-5) they hit the floor with their heel first and travel over their foot until they push off with their toes.  With toe walking the child will either hit the floor with their toes first or the ball of their foot and almost ‘bounce’ onto their toes.  With some kids this is only noticed when they are running and may not be as apparent when they are walking.

Some toe walking is caused by cerebral palsy as a result of the shortening of the calf muscles.  This can be corrected by bracing and/or stretching along with other exercises.  Some kids just walk on their toes for no reason and this is called idiopathic toe walking.

I have found that for the kids that are idiopathic toe walkers they generally outgrow it however some of them don’t.  The biggest concerns I see are that they can develop tightness in their calves (although maybe it was the tightness that was there first).  They also have weaker calves.  We use our calf muscles to keep us from falling as we move our body over our foot while walking.  If our calves are weak and our body doesn’t think it can effectively keep us upright its reaction, in some cases, is to pop up onto our toes.  This isn’t something we think about, it just happens.  Also, you may notice some clumsiness in your child’s running and jumping because they are losing the benefit of the push off that they would get from hitting with their heel, then crossing over their flat foot and then using their calf muscle to push off with their toes to propel them forward.  If they are already on their toes they have no momentum to gain. It would be like trying to get a spring to go that never got compressed.

So, I hope you hear me that idiopathic toe walking is not a big problem unless they are having trouble with clumsiness or running or jumping or other activities that kids like to do!