Pomarino’s disease or persistent forefoot gait is a gait abnormality that occurs in approximately 5% of preschool children. It is often recognized during regular check-ups; However, not all paediatricians can be expected to be aware of the problem. In about half of the cases, Pomarino’s disease “grows together” by school age. Nevertheless, early treatment with insoles and physiotherapy makes sense.
What is Pomarino’s disease?
Pomarino’s disease, the habitual forefoot or tiptoe gait, is named after the Hamburg physiotherapist and occupational therapist David Pomarino, who has been studying and treating the gait disorder intensively for several years. See growtheology for Comprehensive Guide to Hydrops Fetalis.
When walking, those affected only touch down the front part of the ball of their foot and their toes. The roll-off phase is largely absent. Typical for Pomarino’s disease are also the formation of a heel that tapers downwards (so-called pointed heel), a pronounced pes cavus and a widened forefoot with forefoot padding and, very often, a hollow back.
Depending on the clinical picture, three types can be distinguished. Type I occurs in 36% of tiptoe walkers, where the gait anomaly is due to congenital muscle shortening. It is usually not possible for those affected to stand on the entire foot, and their balance is often impaired. In type II toe walkers (52% of cases), the gait disorder tends to run in families.
Patients can stand on the entire surface of their foot and walk with their heel, but only with external rotation of the hip. Type III is the so-called situational toe walking. Here, heel walking is also possible without further ado, those affected only tiptoe in stressful situations. In type III patients, Pomarino’s disease sometimes also includes concentration disorders and behavioral problems, there is no family cluster here.
The causes of Pomarino’s disease are largely unknown. Type I is caused by a congenital shortening of the calf muscle (musculus gastrocnemicus).
Type II is also apparently based on a genetic predisposition. In type III, toe walking is often associated with sensory dysfunction, muscle tone disorders, and general developmental disorders. Hip dysplasia can be another cause of Pomarino disease. There is evidence of an association with pneumonia experienced prior to running.
The habitual tiptoe walking is not based on psychiatric disorders, orthopedic causes or pronounced neuromuscular disorders!
Symptoms, Ailments & Signs
Pomarino’s disease can primarily be recognized by the characteristic gait disturbances. Affected children drag the foot as a result of the anomaly and do not roll off the sole properly. The forefoot is usually associated with a hollow back, which in turn causes severe pain and tension. In the long term, a hollow back leads to poor posture and chronic pain.
As a result of the gait disorder, patients suffer from knee and hip pain as well as balance disorders. In addition, psychological problems can set in, for example depressive moods or feelings of inferiority as a result of bullying and teasing in school and kindergarten. In about 50 percent of all affected children, the symptoms of Pomarino’s disease subside spontaneously.
The sick children then replace the incorrect gait with a normal heel gait, which also means that the pain also subsides after a while. This process can be supported by comprehensive therapy. Some children suffer from gait abnormalities into adulthood. The symptoms can then only be treated with lengthy therapy. Externally, Pomarino’s disease can primarily be recognized by the gait disturbance itself. Other signs can be malformations in the foot area. Depending on the cause, redness or cartilage formation can also occur.
Diagnosis & History
Pomarino’s disease is initially diagnosed based on the typical gait pattern. The examination of the anatomy of the foot and the calf as well as the mobility of the ankle and hip, a rotation and balance test and a precise gait analysis are essential for differentiating between the three types.
Furthermore, electromyographic examinations of the dorsiflexor muscle (musculus tibialis anterior) are necessary. They also serve to differentiate between types and neuromuscular disorders and spastic paralysis, muscular dystrophy and autistic behavior, which are also associated with toe-walking.
In about 50% of cases, Pomarino’s disease heals spontaneously, toe walking is replaced by heel walking. If the gait anomaly persists into adulthood, it usually manifests itself as a rocking gait with pes cavus and widened forefoot. Back or knee pain and hip problems often occur due to the unphysiological stress on the skeleton and muscles.
Type III Pomarino disease has a particularly high rate of spontaneous healing. But the prognosis for types I and II is also excellent if the disorder is treated before the age of 5 years. Over 90% of patients are cured within a year, long-term effects do not occur. If the treatment starts later, it is usually more complex, but also promises good success.
Due to Pomarino’s disease, the patient has significant limitations in everyday life and thus a severe reduction in quality of life. In most cases, this disease leads to restricted mobility and also to severe gait disorders. Those affected suffer from an unsteady gait and also from disturbances in concentration and coordination.
When walking, the front foot in particular is subjected to stress, which can lead to consequential damage later in life. It is not uncommon for those affected to suffer from a so-called hollow back, which can lead to significant limitations and pain in everyday life. Furthermore, Pomarino’s disease can lead to paralysis and other sensory disorders.
The patient’s resilience also drops significantly and the patient often exhibits autistic behavior. The knees can hurt and lead to irritability of the affected person. With the help of insoles, Pomarino’s disease can be significantly reduced and treated relatively well.
Complications usually do not arise. Mental health problems can be treated by a psychologist. As a rule, the patient’s life expectancy is not reduced or restricted by Pomarino’s disease. In most cases, however, the treatment lasts between one and two years.
When should you go to the doctor?
When a gait abnormality called Pomarino’s disease occurs in preschool age, the condition is usually diagnosed during one of the routine check-ups at the pediatrician or school doctor. The tiptoe or forefoot walk often takes care of itself when the children get older.
Nevertheless, it is advisable to consider physiotherapeutic treatment. The reason is any muscle shortening that causes the gait anomaly in type 1 Pomarino disease. The effects of such muscle shortening can be corrected or mitigated. The balance disorders occasionally associated with the disease can also be treated.
In the case of Pomarino’s disease types 2 and 3, the situation is somewhat different. In the case of type 3 Pomarino disease, the doctor is usually consulted because of the gait anomaly. Here it is associated with developmental disorders, sensory malfunctions or muscle tone disorders.
Parents usually do not take their children to the doctor because of a gait abnormality. Gait abnormalities often do not cause any further symptoms. Most parents are therefore not aware of a disease called Pomarino’s disease. Nevertheless, to be on the safe side, an orthopedist should be consulted in the event of abnormal gait. In the course of Pomarino’s disease, knee or hip problems or a pronounced hollow back can occur. If Pomarino’s disease type 3 is present, other symptoms can also be expected. It is therefore useful to clarify the causes of gait anomalies.
Treatment & Therapy
The early treatment of Pomarino’s disease consists mainly of fitting special pyramid insoles according to Pomarino®. In type I, physical therapy is often used to encourage stretching of the Achilles tendon. If other problems such as a hollow back or restricted mobility of the ankle joints are already present, supportive physiotherapy treatment is prescribed.
The treatment is usually completed after 6 to 24 months. If there is little or no improvement, the normal position of the foot can be forced by orthoses, casts or night splints, usually in combination with paralysis of the calf muscle by injection of botulinum toxin. Surgical correction of the Achilles tendon is only resorted to when all other therapy methods have been exhausted.
In type III, the course is usually observed in a wait and see manner. Occupational therapy may be indicated if concentration disorders and behavioral problems occur at the same time as the gait anomaly.
Outlook & Forecast
Gait anomaly Pomarino’s disease offers a good prognosis. The condition can be easily corrected with physiotherapy and drug treatment. In 50 percent of the cases, spontaneous healing occurs by replacing the toe walk with the heel walk. A chronic gait anomaly causes pain and leads to malpositions such as the typical rocking gait. For those affected, this is sometimes associated with severe physical discomfort and reduced well-being. Treatment is also possible for advanced diseases.
The prospects are particularly good if the disorder is diagnosed and treated by the age of five. In this case, 90 percent of patients can be cured within a year. Late effects are unlikely in a healed Pomarino’s disease. Damage to the joints and bones that has already occurred can be treated surgically or with medication.
Alternatively, the symptoms can be significantly reduced with the help of insoles. Psychological side effects are treated as part of a therapy. Life expectancy is not limited by Pomarino’s disease. Treatment lasts between 12 and 24 months, depending on the time of diagnosis and the severity of the condition.
Preventing Pomarino’s disease is not possible. The gait anomaly occurs as early as the first attempt to walk. However, timely therapy with insoles ensures that the disorder heals without long-term effects. General foot health measures such as well-fitting shoes and frequent barefoot walking also improve the prognosis for Pomarino’s disease.
Pomarino’s disease does not always require treatment. The toe walk sometimes recedes on its own or is only weak and does not cause any symptoms. Follow-up care is based on whether and which therapeutic measures have been taken.
The specialist will check the gait and, if necessary, initiate physiotherapy again or suggest measures for the patient to correct the toe walking at home. Follow-up care for severe Pomarino’s disease also involves the podiatrist. The specialist checks whether joint damage, malpositions and other typical symptoms of toe walking have been healed.
After a surgical procedure, a comprehensive examination of the feet and, if necessary, the spine must be carried out as part of the aftercare. Follow-up care also includes a patient consultation. This anamnesis serves to identify and treat any subsequent symptoms of the therapy at an early stage.
In addition, open questions of the child can be clarified. The treatment is followed by therapy for the causative disease, such as ADHD or autism. In any case, the affected child must be closely observed so that a quick reaction can be made if the toe-walking returns.
You can do that yourself
The disease occurs mostly in children. These are naturally in a growth and development process. During this time, care should be taken to ensure that suitable footwear is worn. It must be neither too small nor too large, so that no incorrect posture is triggered. In addition, children should wear closed shoes that do not have high heels to move around.
Being overweight should be avoided as it leads to an increase in symptoms. The recommended weight can be found in the BMI. A balanced and healthy diet prevents weight gain. Sufficient physical activities are also recommended as compensation. Overexertion or excessive strain on the organism and especially on the skeletal system should be avoided. The activities and demands on the child must be adapted to the available possibilities so that no situation of excessive demands occurs.
Sufficient rest and recovery phases should be included in everyday life. As soon as pain occurs or the first problems in the joints appear, the stresses must be reduced. Sports activities should be adapted to physical capacities. Extreme sports should not be practiced.
The symptoms can lead to psychological stress. So that the well-being is stabilized and strengthened, activities with the child are recommended that promote joie de vivre and build self-confidence.