Ovid: Pediatrics

Editors: Tornetta, Paul; Einhorn, Thomas A.; Cramer, Kathryn E.; Scherl, Susan A.
Title: Pediatrics, 1st Edition
> Table of Contents > Section I: – Outpatient Clinic > 9 – Toe-Walking

Brian L. Hotchkiss
Toe-walking is commonly seen in children, and it is
often undertreated. Characteristically the child walks with the foot in
an equinus posture, bearing weight mostly or entirely on the forefoot.
The child may be able to get the heel down volitionally when standing
or walking. This has led to the misleading terms of “habitual” or
“volitional” toe-walking. Toe-walking may be a transient developmental
variant, associated with neuromuscular conditions, or it may be
idiopathic. If persistent into the third year of life, toe-walking
deserves medical attention and will likely require treatment.
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.
Natural History
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.
History and Physical Examination
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


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:
  • Shortened Achilles tendon is the most obvious.
  • Difference in the appearance of the plantar skin.
    • □ The forefoot skin is thickened and may be calloused.
    • □ Heel skin is smooth and thinner.
  • Underdevelopment of the calcaneus and
    overdevelopment of the forefoot, leading to wedge-shaped foot with a
    narrow undeveloped heel and a wide overdeveloped forefoot
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.
The role of physical therapy and coaching (instructing
the child to volitionally stop walking on toes) for management of
idiopathic toe-walking are poorly documented but do not seem to be
effective in clinical experience.
Serial casting for a period of 6 to 8 weeks is commonly
used, especially in younger children. After casting it may be advisable
to splint the ankle in dorsiflexion at night for 6 months and to
encourage the parents to perform daily passive stretching techniques
during the same time.
Percutaneous heel cord lengthening may be employed as a primary option or as a fallback option for unsuccessful cast treatment.
Botox injection into the triceps surae may be an
alternative to consider in children who have failed cast treatment if
they don’t have significant heel cord shortening.
Results and Outcome
Despite various observations and opinions found in
recent articles in the medical literature, I have found consistent
success with casting and night splinting:
  • Two sets of short leg walking casts are worn for periods of 3 weeks each.
  • The casts are applied with the child’s forefoot resting on a metal support.
  • The foot is kept in maximum dorsiflexion
    (the child is instructed to drop the heel toward the floor while the
    parent holds gentle pressure down on the knee).
  • Care must be taken not to dorsiflex the
    foot after the cast material is wrapped to avoid a pressure sore over
    the anterior ankle.
  • If the heel cords are quite short or the child is in the older age group, 3 sets of casts are worn for 2 weeks each.
  • All children are kept in dorsiflexion night splints for 6 months.
  • Parents are instructed on daily calf muscle stretching.
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.
B, Davidson LK, Olney SJ. Serial casting in idiopathic toe-walkers and
children with spastic cerebral palsy. J Pediatr Orthop 2000;20:221-225.
DM, Menelaus MB, Dickens DRV, et al. Idiopathic toe-walking: does
treatment alter the natural history? J Pediatr Orthop (Part B)
PP, Wheelhouse WW, Shiavi R, et al. Habitual toe-walkers: a clinical
and electromyographic gait analysis. J Bone Joint Surg (Am)
Kogan M, Smith J. Simplified approach to idiopathic toe-walking. J Pediatr Orthop 2001;21:790-791.
JF, Torburn L, Rinsky LA, et al. Electromyographic test to
differentiate mild diplegic cerebral palsy and idiopathic toe-walking.
J Pediatr Orthop 2001;21:784-789.
Stricker SJ, Angulo JC. Idiopathic toe walking: a comparison of treatment methods. J Pediatr Orthop 1998;18:289-293.

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