Pomarino’s disease, or persistent forefoot gait, is a gait abnormality that occurs in approximately 5% of preschool children. It is often detected during regular screening examinations; however, awareness of the problem cannot yet be assumed among all pediatricians. In about half of the cases, Pomarino’s disease “grows out” by school age. Nevertheless, early treatment with orthotics and physiotherapy is useful.
What is Pomarino’s disease?
Pomarino disease, or habitual forefoot or toe-to-toe gait, is named after David Pomarino, a Hamburg-based physiotherapist and occupational therapist who has intensively studied and treated the gait disorder for several years. Affected persons sit up only the front part of the ball and the toes when walking. The rolling phase is largely absent. Typical for Pomarino’s disease are furthermore the development of a downward tapering heel (so-called pointed heel), a pronounced hollow foot and a widened forefoot with forefoot padding as well as very often a hollow back. Depending on the clinical picture, three types can be distinguished. Type I occurs in 36% of toe walkers, here the gait abnormality is due to a congenital muscle shortening. Stance on the entire foot surface is usually not possible for those affected, and their balance is often impaired. In type II toe-walkers (52% of cases), the gait disorder runs in families. Patients can stand on the entire foot surface and walk in heel gait, but only with external rotation of the hip. Type III is the so-called situational toe gait. In this case, heel gait is also possible without further ado, and those affected only lapse into toe-to-toe gait in stressful situations. In type III patients, Pomarino’s disease sometimes also includes concentration disorders and behavioral problems; there is no familial clustering here.
Causes
The causes of Pomarino disease are largely unexplained. Type I is caused by a congenital shortening of the calf muscle (gastrocnemius muscle). Type II also appears to be based on a genetic predisposition. In type III, toe-to-toe gait is often associated with sensory dysfunction, muscle tone disorders, and general developmental abnormalities. Hip dysplasia may be another cause of Pomarino disease. There is evidence of an association with pneumonia experienced prior to the onset of running. Psychiatric disorders, orthopedic causes, or marked neuromuscular disorders do not underlie habitual toe-tapping!
Symptoms, complaints, and signs
Pomarino’s disease can be recognized primarily by the characteristic gait abnormalities. Affected children drag the foot as a result of the abnormality and do not roll the sole properly. The forefoot gait is usually associated with a hollow back, which in turn causes severe pain and tension. In the long term, a hollow back leads to postural deformities 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 complaints can develop, for example depressive moods or feelings of inferiority as a result of bullying and teasing at school and kindergarten. In about 50 percent of all affected children, the symptoms of Pomarino’s disease resolve spontaneously. The affected children then replace the incorrect gait with a normal heel gait, whereby the pain also decreases after some time. This process can be supported by comprehensive therapy. Some children suffer from gait abnormalities until adulthood. The symptoms can then only be treated by a prolonged therapy. Externally, Pomarino’s disease is primarily recognized by the gait disorder itself. Further signs can be malformations in the area of the foot. Depending on the cause, there may also be redness or cartilage formation.
Diagnosis and progression
Pomarino’s disease is initially diagnosed based on the typical gait pattern. Examination of the anatomy of the foot and calf as well as the mobility of the ankle and hip, a rotation and balance test, and an accurate gait analysis are essential to differentiate the three types. Furthermore, electromyographic examinations of the foot elevator muscle (Musculus tibialis anterior) are necessary. They also serve to differentiate the types as well as to distinguish them from neuromuscular disorders and spastic paralysis, muscular dystrophy and autistic behavior, which are also associated with toe gait.In about 50% of cases, Pomarino’s disease heals spontaneously, and the toe-to-toe gait is replaced by the heel gait. If the gait abnormality persists into adulthood, it usually manifests as a teetering gait pattern with hollow feet and widened forefeet. Often, back or knee pain and hip problems occur due to the non-physiological stress on the skeleton and muscles. Type III Pomarino’s disease has a particularly high spontaneous recovery rate. However, the prognosis for type I and II is also excellent if the disorder is treated before the age of 5. More than 90% of patients are cured within one year, and late complications do not occur. If treatment begins later, it is usually more costly but also promises good success.
Complications
Due to Pomarino’s disease, the patient experiences significant limitations in everyday life and thus a strong reduction in quality of life. In most cases, this disease leads to movement restrictions and further to severe gait disturbances. Patients suffer from gait instability and also from disturbances in concentration and coordination. During gait, especially the front foot is stressed, which can lead to consequential damage in later life. It is also not uncommon for those affected to suffer from a so-called hollow back, which can lead to significant limitations and also to pain in everyday life. Furthermore, Pomarino’s disease can lead to paralysis and further disturbances of sensibility. Likewise, the resilience of the patient decreases significantly and autistic behavior of the patient often occurs. The knees may hurt, leading to irritability of the affected person. With the help of orthotics, Pomarino’s disease can be significantly limited and relatively well treated. Complications usually do not occur. Psychological complaints can be treated by a psychologist. As a rule, Pomarino’s disease does not reduce or limit the patient’s life expectancy. However, treatment usually lasts between one and two years.
When should you see a doctor?
When a gait abnormality called Pomarino’s disease occurs in preschoolers, the condition is usually detected during one of the routine exams with a pediatrician or school doctor. The toe-to-toe or forefoot gait often resolves itself as the children grow. Nevertheless, it is recommended to consider physiotherapeutic treatment. The reason may be muscle shortening, which causes the gait abnormality in Pomarino’s disease type 1. The effects of such muscle shortening can be corrected or mitigated. The balance problems that occasionally accompany the disease can also be treated. In Pomarino’s disease types 2 and 3, the situation is somewhat different. In Pomarino’s disease type 3, the doctor is usually consulted because of the gait abnormality. In this case, it is accompanied by developmental disorders, sensory dysfunction, or muscle tone disorders. Usually, parents do not take their children to the doctor because of a gait abnormality. Gait abnormalities often do not cause any other symptoms. Therefore, most parents are not aware of a disease called Pomarino’s disease. Nevertheless, an orthopedist should be consulted to be on the safe side in case of gait abnormalities. In the course of Pomarino’s disease, knee or hip problems or a pronounced hollow back may occur. If Pomarino’s disease type 3 is present, other symptoms are also to be expected. Therefore, clarification of the causes of gait abnormalities is useful.
Treatment and therapy
Early therapy of Pomarino disease consists mainly of fitting special pyramidal insoles according to Pomarino. In type I, additional physical therapy is often used to promote stretching of the Achilles tendon. Also, if other problems such as a hollow back or limited mobility of the ankle joints are already present, supportive physiotherapy treatment is prescribed. As a rule, treatment is 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 tendons is resorted to only when all other therapeutic methods have been exhausted. In type III, the course is usually observed in a wait-and-see manner.If concentration problems and behavioral abnormalities occur concurrently with the gait abnormality, occupational therapy may be indicated.
Outlook and prognosis
Pomarino disease gait abnormality offers a good prognosis. The condition can be well corrected with physical therapy and drug treatment. Spontaneous recovery occurs in 50 percent of cases, with toe-off gait being replaced by heel gait. A chronic gait anomaly causes pain and leads to malpositions such as the typical teetering gait. This is sometimes associated with severe physical discomfort and a limited sense of well-being for those affected. 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 if Pomarino’s disease is cured. Damage that has already occurred to the joints and bones can be treated surgically or with medication. Alternatively, the symptoms can be significantly reduced with the help of insoles. Psychological side effects are treated within the framework of therapy. Life expectancy is not limited by Pomarino’s disease. Treatment lasts between twelve and 24 months, depending on the time of diagnosis and the severity of the condition.
Prevention
Preventing Pomarino disease is not possible. The gait abnormality occurs during the first attempts to walk. However, timely therapy with orthotics ensures that the disorder heals without late effects. General foot health measures such as well-fitting shoes and frequent barefoot walking also improve the prognosis in Pomarino disease.
Follow-up care
Pomarino disease does not always require treatment. Tiptoeing sometimes regresses on its own or is mild and does not cause symptoms. Follow-up care is based on whether therapy measures have been undertaken and, if so, which ones. The specialist checks the gait and, if necessary, can initiate a resumption of physiotherapy or suggest measures that the patient can use to correct the tiptoe gait himself at home. Follow-up care for severe Pomarino’s disease also involves the podiatrist. The specialist checks whether joint damage, malpositions and other typical secondary symptoms of tiptoe gait have been cured. After a surgical procedure, a comprehensive examination of the feet and, if necessary, the spine must be performed as part of the follow-up care. Follow-up care also includes a patient interview. This anamnesis serves to identify and treat any subsequent complaints of the therapy at an early stage. In addition, open questions from the child can be clarified. The treatment is followed by therapy for the causative disorder, such as ADHD or autism. In any case, the affected child must be well observed so that a quick response can be made if the toe-tapping gait returns.
What you can do yourself
The condition occurs mostly in children. These are naturally in a process of growth and development. During this time, care should be taken to wear appropriate footwear. It should be neither too small nor too large, so that no bad posture is triggered. In addition, children should wear closed shoes for locomotion that do not have high heels. Excess weight should be avoided, as it leads to an increase in symptoms. The recommended weight can be taken from the BMI. Weight gain is avoided with a balanced and healthy diet. In addition, sufficient physical activities are recommended as compensation. Overexertion or excessive strain on the organism and primarily on the skeletal system should be avoided. The activities and demands on the child should be adapted to the available possibilities so that no overstraining situation occurs. Sufficient rest and recovery phases are to be included in everyday life. As soon as pain occurs or the first problems with the joints arise, the demands should be reduced. Sports activities should be adapted to physical capacities. Extreme sports should be avoided. The discomfort may cause psychological stress. In order to stabilize and strengthen the child’s well-being, it is advisable to engage in activities with the child that promote joie de vivre and build self-confidence.
