Toe-Walking

Toe-walking may be developmental, associated with
another condition, or idiopathic. Developmental toe-walking is common
in normal children during the first year of ambulation. It is bipedal
and self-limited. If it is unilateral, other conditions such as
developmental hip dislocation, congenitally short femur, or hemiplegia
need to be considered.

An associated condition such as cerebral palsy, spinal
cord anomaly, muscular dystrophy, or other neurologic conditions needs
to be ruled out by history, examination, and diagnostic testing.

Idiopathic toe-walking begins like the developmental
type but does not resolve. The diagnosis is established by exclusion if
careful exam does not reveal spasticity or other sign of a more
generalized neuromuscular disorder.

The child who rises on toes during stance but makes
consistently good heel contact is probably developing normally and is
not included in this discussion.

The cause of toe-walking in otherwise normal children is unknown. There may by a family history of a similar condition.

Children with idiopathic toe-walking have been shown to
have abnormal electromyographic gait analysis findings. The muscle
synergy pattern is abnormal during the toe-toe gait as well as during
the heel-toe gait. These changes are reversible with cast treatment.
The forefoot adjusts to its weightbearing role by hypertrophy. The heel
adjusts to its non-weightbearing role by atrophic growth.

It is generally agreed upon that toe-walking in the
first year or two of life has a benign prognosis. There is poor
agreement in the literature regarding the prognosis in older children.
Although some children are said to improve spontaneously, others do
not. Persistence leads to enduring gait abnormality, structural foot
deformity, and difficulty with shoe wear. Treatment appears to be most
effective in children under 5 years of age. The effect of excessive
weightbearing by the forefoot in aging adults is not well documented.

The typical child presents with a history of normal
motor development. The toe-walking pattern has usually been present
since walking began. It may be static or dynamic. If ankle dorsiflexion
can be brought to neutral or beyond, the child can stand flat-footed or
walk with the heel down during the initial stance phase of gait. In the
static form, the shorter heel cords make it necessary for the child to
compensate by knee hyperextension in order to get the heel down. In the
less common dynamic form, the range of motion of the ankle is normal.
In either form, as soon as the child stops concentrating on walking
correctly, the toe-toe gait pattern returns.

If the toe-walking is unilateral, and the bone and joint
structure of the extremity is normal, the cause is most likely
hemiplegic cerebral palsy. Sustained ankle clonus, abnormal accessory
movements of upper extremities during

gait,
clumsiness with hopping (especially in older children), muscle
hypertrophy or atrophy, autism, learning difficulties, bladder
problems, cavus feet, or other signs of neurologic impairment need to
be considered before settling on a diagnosis of idiopathic toe-walking.

Aside from the characteristic gait abnormality, there
are three other characteristic physical findings seen in children who
walk on their toes:

Careful examination of the foot can be more important
than the observation of walking in the atypical environment of the
outpatient clinic. The diagnostic workup is outlined in Box 9-1.

Despite various observations and opinions found in
recent articles in the medical literature, I have found consistent
success with casting and night splinting:

Recurrences are not common and heel cord lengthening is
only infrequently needed. If the condition has been allowed to persist
beyond 4 or 5 years of age, treatment is more difficult. Primary care
physicians should be encouraged to refer patients between 2 and 3 years
of age to orthopaedists.