Table of Contents
Basics
Toe walking is a walking pattern in which a child walks on balls of his feet, with no contact between the heels & ground.
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
Toe Walking Treatment in Singapore
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.
Appointment
If you would like an appointment / review with our toe walking specialist in Singapore, the best way is to call +65 6664 8135 or click here to book an appointment at the clinic. If you would like to speak to one of our clinicians first about e.g.tip toe walking treatment, idiopathic toe walking, gait analysis, toe walking surgery etc, then please contact feedback2@bone.com.sg or SMS/WhatsApp to +65 6664 8135.
Rest assured that the best possible care will be provided for you.
