Toe Walking

• 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.

• Usually noted when a child begins to walk

• Positive family history
• History of premature birth
• Low Apgar score

• Neuromotor patterning
• Shortened Achilles tendon

Signs and Symptoms

• 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.

• Arthrogryposis
• Cerebral palsy
• Familial spastic paraparesis
• Muscular dystrophy
• Tethered cord syndrome
• Charcot-Marie-Tooth disease

• 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.

• 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

• 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.

• Undiagnosed neurologic abnormality
• Overlengthening of the heel cord
• Recurrence

• 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