Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Toe Walking

Basics

Description
  • Idiopathic toe walking in toddlers is common.
  • Most commonly caused by a shortened Achilles tendon
  • Some of these children eventually adopt normal walking patterns with growth.
  • Persistent and exclusive toe walking beyond 3 years of age should prompt an examination for underlying neuromuscular problems.
  • However, most children have what is termed, by exclusion, idiopathic toe walking.
Epidemiology
Usually noted when a child begins to walk
Incidence
Common
Prevalence
Both genders equally affected
Risk Factors
  • Positive family history
  • History of premature birth
  • Low Apgar score
Genetics
Up to 50% of patients have a positive family history.
Etiology
  • Neuromotor patterning
  • Shortened Achilles tendon
Diagnosis
  • Idiopathic toe walking is diagnosed on the basis of the history and physical examination.
  • A diagnosis of exclusion:
    • Neuromuscular abnormality must 1st be excluded.
Signs and Symptoms
Physical Exam
  • Examination should be made with the child wearing shorts.
  • Note the position of the feet during all phases of walking and standing.
  • Perform neurologic examination to detect spasticity or myopathy.
  • Note the range of ankle dorsiflexion, with the knee both flexed and extended.
  • Palpate the calf for any abnormal masses.
  • Examine the hamstrings and adductors for tightness.
  • Document passive and active ankle ROM.
Tests
  • Additional testing is indicated only if the physical examination suggests a neurologic or myopathic cause.
  • Computerized gait analysis may differentiate a child with mild cerebral palsy from an idiopathic toe walker.
    • An out-of-phase gastrocnemius complex on electromyographic analysis strongly suggests a neurologic abnormality in a toe walker.
  • Creatinine phosphokinase, muscle biopsy, or mutation analysis may be useful if a dystrophic process is suspected.
Imaging
MRI of the spine may be performed if a suspected spinal abnormality is causing spasticity.
Differential Diagnosis
  • Arthrogryposis
  • Cerebral palsy
  • Familial spastic paraparesis
  • Muscular dystrophy
  • Tethered cord syndrome
  • Charcot-Marie-Tooth disease
Treatment
General Measures
  • Stretching and encouragement are the usual 1st-line means of treatment.
  • Orthotics, by themselves, do not seem to be effective.
  • Casting:
    • Increased ankle dorsiflexion can be achieved by stretching and serial casting, placing the foot in maximum dorsiflexion (i.e., at least 10° of ankle dorsiflexion, while allowing the normal heel–toe gait to develop).
    • The cast should be changed weekly until the desired ankle ROM is obtained.
  • Initially, patients should be seen weekly for cast changes.
  • Night braces with the ankle in maximal dorsiflexion may be helpful for maintaining the dorsiflexion achieved with casting or surgery.
Special Therapy
Physical Therapy
  • Passive and active ROM exercise of the ankles may be used to treat patients with mild cases.
  • If the ROM of the ankle allows some dorsiflexion, teaching children to practice walking on the heels may help to enforce a normal gait pattern.
Surgery
  • If other methods fail, Z-lengthening of the Achilles tendon can improve ankle dorsiflexion.
    • May be done through percutaneous or open methods
    • Usually performed if a child does not adopt a normal gait pattern by the start of school years

P.467
Follow-up
Disposition
Issues for Referral
  • Toe walking begins de novo after a period of normal heel toe gait.
  • A child does not improve by the start of kindergarten.
  • Patients should be referred to a pediatric orthopaedic surgeon if possible.
Prognosis
  • Many idiopathic toe walkers develop a normal gait by the age of 3 years.
  • Persistent toe-strike gait into maturity may cause problems with metatarsal callous formation and impaired balance.
Complications
  • Undiagnosed neurologic abnormality
  • Overlengthening of the heel cord
  • Recurrence
Miscellaneous
Codes
ICD9-CM
727.81 Toe walking
Patient Teaching
  • Patients and their families may be instructed to perform home heel-cord stretching exercises and heel walking at home.
  • Some idiopathic toe walkers can assume a heel toe gait with persistent persuasion.
FAQ
Q: What is the cause of toe walking if other usual causes are excluded?
A: It is likely that a subtle difference in central locomotor patterning is present.
Q: Will a child grow out of the habit of TOE_WALKING?
A: Many children will do so before the start of kindergarten. However, if the child does not, referral to a specialist is indicated.

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