Toe Walking

By admin Last updated Mar 15, 2024

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.

Title: 5-Minute Orthopaedic Consult, 2nd Edition

> Table of Contents > Toe Walking

Toe Walking

Paul D. Sponseller MD

Basics

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 (1,2).

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

Treatment

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 (3).
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 (3).

Surgery

If other methods fail, Z-lengthening of the Achilles tendon can improve ankle dorsiflexion.
- May be done through percutaneous or open methods (1,3)
- 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

References

1. Hemo
Y, Macdessi SJ, Pierce RA, et al. Outcome of patients after Achilles
tendon lengthening for treatment of idiopathic toe walking. J Pediatr Orthop 2006;26:336–340.

2. Kalen V, Adler N, Bleck EE. Electromyography of idiopathic toe walking. J Pediatr Orthop 1986;6:31–33.

3. Eiff
MP, Steiner E, Judkins DZ. Clinical inquiries. What is the appropriate
evaluation and treatment of children who are “toe walkers”? J Fam Pract 2006;55:447,450.

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.