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"S" Case Information 

9 year old boy

Health condition: “toe walking”. Has always walked on his toes, pediatrician said he would grow out of it. Mother’s sister is an adult PT, who saw him recently and recommended he be seen for toe walking.

Patient Goal(s) - "shrug"

Caregiver Goal(s) - Mother and father: to prevent pain and problems in the future due to toe walking.

Reactive skin (red skin due to using night-stretch braces)

Parents deny any history of sensory processing or GERD, though he did have pyloric stenosis as an infant. No other diagnoses.

Neurotypical in language use, at grade level in school.

Musculoskeletal Findings

  1. Functional Variants

  2. DF Stress test: 1-Neutral hindfoot          

End feel: active resistance/GS/heelcord                            

  1. Joint function range

Talo-crural         -25/-30 L, 0 R

NM: tonic contraction of GS, peroneals, post tibialis, long toe extensors

Sensory and Pain: Experiences pain/discomfort with:

  • Tactile input to LEs, worsening the more distal

  • range of motion

  • Use of stiff soled shoes


Individual: Reports that he likes to play sports including basketball and football.

PM&R: Referred for serial casting but “does not refer toe walkers for PT”


Case 1

Case 1

Exam questions :

Functional status: 

Loading response: What is S’s movement system’s strategy for shock absorption during loading response? How well is it working on the right versus left?

​Midstance: Does S have (1) shank within functional limits, (2) excessively reclined shank, or (3) excessively reclined shank?

​Terminal stance: What elements are lacking for therapeutic gait?

What powers swing for S?

Musculoskeletal findings:

What structures are receiving excessive stress in the movement system?

Which muscles have an altered line of pull?

Neuromotor and Motor control findings:

In which muscle groups do you observe

·       Impaired timing for function?

·       Altered tonic contraction?

​What strategies are available to S for balance reactions?

Sensory Perception and Pain:

What is your hypothesis for the usefulness of S’s lower extremity cortical map for function?

Relevant systems screening:

What systems might be contributing to S’s gait impairments? Any referrals you want to make?


           S reports that he participates basketball and football with neurotypical peers. What’s your guess around his sports performance? If S wants to participate in structured team sports like football, what uniform issue might he have?


Key findings: What are the suspected drivers and limiting factors for S?


What are relevant goals for S?

Body Structure and function:

9 year old S: 

Adult S: 


9 year old S: 

Adult S: 

Environment, Participation, and Personal Factors:

9 year old S: 

Adult S: 

​What are goal areas that might be in conflict (ICF levels/family goals/patient goals/team member goals)? Who is right?


Pain and Health Condition Education:

Discuss 3 strategies you will use to decrease S’s pain.

Neuroplasticity questions :

Demonstrate/describe 3 (different from the pain strategies above) activities to promote neuroplasticity/cortical map plotting of the LEs for S. Bonus points for creative activities/games NOT mentioned in the manual. How will you progress the complexity for cortical map development?


Manual Therapy:

Demonstrate the joint mobilizations that might be appropriate for S.

Demonstrate the soft tissue mobilizations that might be appropriate for S.

How might you modify techniques for S?

Strengthening questions :

Improved strength in what 3 muscle groups would make the biggest functional difference for S?

Demonstrate the progressive resistive exercises you plan to do with S. How will you modify for him?

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