Basics
Description
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Idiopathic toe walking in toddlers is common.
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Most commonly caused by a shortened Achilles tendon
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Some of these children eventually adopt normal walking patterns with growth.
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Persistent and exclusive toe walking beyond 3 years of age should prompt an examination for underlying neuromuscular problems.
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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
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Positive family history
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History of premature birth
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Low Apgar score
Genetics
Up to 50% of patients have a positive family history.
Etiology
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Neuromotor patterning
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Shortened Achilles tendon
Diagnosis-
Idiopathic toe walking is diagnosed on the basis of the history and physical examination.
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A diagnosis of exclusion:
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Neuromuscular abnormality must 1st be excluded.
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Signs and Symptoms
Physical Exam
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Examination should be made with the child wearing shorts.
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Note the position of the feet during all phases of walking and standing.
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Perform neurologic examination to detect spasticity or myopathy.
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Note the range of ankle dorsiflexion, with the knee both flexed and extended.
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Palpate the calf for any abnormal masses.
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Examine the hamstrings and adductors for tightness.
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Document passive and active ankle ROM.
Tests
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Additional testing is indicated only if the physical examination suggests a neurologic or myopathic cause.
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Computerized gait analysis may differentiate a child with mild cerebral palsy from an idiopathic toe walker.
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An out-of-phase gastrocnemius complex on electromyographic analysis strongly suggests a neurologic abnormality in a toe walker.
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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
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Arthrogryposis
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Cerebral palsy
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Familial spastic paraparesis
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Muscular dystrophy
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Tethered cord syndrome
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Charcot-Marie-Tooth disease
TreatmentGeneral Measures
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Stretching and encouragement are the usual 1st-line means of treatment.
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Orthotics, by themselves, do not seem to be effective.
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Casting:
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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).
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The cast should be changed weekly until the desired ankle ROM is obtained.
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Initially, patients should be seen weekly for cast changes.
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Night braces with the ankle in maximal dorsiflexion may be helpful for maintaining the dorsiflexion achieved with casting or surgery.
Special Therapy
Physical Therapy
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Passive and active ROM exercise of the ankles may be used to treat patients with mild cases.
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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
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If other methods fail, Z-lengthening of the Achilles tendon can improve ankle dorsiflexion.
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May be done through percutaneous or open methods
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Usually performed if a child does not adopt a normal gait pattern by the start of school years
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P.467
Follow-upDisposition
Issues for Referral
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Toe walking begins de novo after a period of normal heel toe gait.
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A child does not improve by the start of kindergarten.
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Patients should be referred to a pediatric orthopaedic surgeon if possible.
Prognosis
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Many idiopathic toe walkers develop a normal gait by the age of 3 years.
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Persistent toe-strike gait into maturity may cause problems with metatarsal callous formation and impaired balance.
Complications
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Undiagnosed neurologic abnormality
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Overlengthening of the heel cord
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Recurrence
MiscellaneousCodes
ICD9-CM
727.81 Toe walking
Patient Teaching
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Patients and their families may be instructed to perform home heel-cord stretching exercises and heel walking at home.
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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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