Toe walking

Toe walking refers to a condition where a person walks on their toes without putting much weight on the heel or any other part of the foot. Toe walking in toddlers is common. These children usually adopt a normal walking pattern as they grow older. If a child continues to walk on their toes past the age of three, they should be evaluated by a doctor.[1]

Toe walking
SpecialtyPediatrics

Toe walking can be caused by different factors. One type of toe walking is also called "habitual" or "idiopathic" toe walking, where the cause is unknown.[2] Other causes include a congenital short Achilles tendon, muscle spasticity (especially as associated with cerebral palsy) and paralytic muscle disease such as Duchenne muscular dystrophy.[3] A congenital shortening of the Achilles tendon can be hereditary, can take place over time as the result of abnormal foot structure which shortens the tendon, or can shorten over time if its full length is not being used. Toe walking is sometimes caused by a bone block located at the ankle which prevents the antagonist movement, dorsiflexion. This cause is often associated with trauma or arthritis.[4] It may also be one way of accommodating a separate condition, foot drop. Persistent toe walking in children has been identified as a potential early sign of autism.[5][6]

Toe walking has been found to be more prevalent in males than females when tested with very large numbers of children. This study looked for family history of toe walking and the connection to children demonstrating idiopathic toe walking (ITW). 64.2% of the subjects with ITW were males showing a relationship between ITW and males. Of 348 subjects with positive family history of toe walking, about 60% had family history on the paternal side showing it may be genetically related to paternal genes. [7] In 30–42% of idiopathic toe walkers, a family link has been observed.[8]

Cause

Unknown

Idiopathic toe walking can be described as bilateral toe walking with no orthopedic or neurological cause past the age of two. [9] In this condition, children are able to voluntarily walk with the normal heel-toe pattern, but prefer to walk with the toe-toe pattern. In order for it to be considered idiopathic, the child's medical history should be clear of any neurological, orthopedic, or neuro-psychiatric conditions including other gait abnormalities. [10] [11] Two classifications of idiopathic toe walking have been established. The Alvarez's classification identifies the severity of the dysfunction based upon kinematics and ankle rockers. The Pomarino classification identifies the toe walking according to the individual's specific characteristics and characterizes them into three types based on the signs presented. [12] Diagnosis includes a spin test, walking, heel walking, dorsiflexion range of motion, and lumbar lordosis. [13] Some treatment options include serial casting and surgery for ankle motion. [14]

Cerebral palsy

Studies have been performed to determine the source of the association between toe walking and cerebral palsy patients. One study suggests that the toe walking—sometimes called an equinus gait—associated with cerebral palsy presents with an abnormally short medial and lateral gastrocnemius and soleus—the primary muscles involved in plantarflexion. A separate study found that the gait could be a compensatory movement due to weakened plantarflexion muscles.[15] The study performed clinical studies to determine that a greater plantarflexion force is required for normal heel-to-toe walking than for toe walking. Able bodied children were tasked to perform gaits at different levels of toe walking and the study discovered that their toe walking could not reduce the force to the levels that cerebral palsy patients indicated in their walk. This suggests that cerebral palsy in which an equinus gait is present may be due to abnormally weakened plantarflexion that can only manage toe walking.[16]

Diagnosis

A doctor will typically evaluate whether there is bilateral (both legs) toe walking, what the child's range of motion is (how far they can flex their feet) and perform a basic neurological exam. Treatment will depend on the cause of the condition.[17]

Treatment

For idiopathic toe walking in young children, doctors may prefer to watch and wait: the child may "outgrow" the condition.[18] If there is a reduction in the child's range of motion, there are several options.[3]

  • Wearing a brace or splint either during the day, night or both which limits the ability of the child to walk on their toes and stretches the Achilles tendon. One type of brace used is an AFO (ankle-foot orthosis).
  • Serial casting where the foot is cast with the tendon stretched, and the cast is changed weekly with progressive stretching. However, these casts may not be changed weekly and instead every 2–3 weeks.
  • Botox therapy is used to paralyze the calf muscles to reduce the opposition of the muscles to stretching the Achilles tendon, usually together with serial casting or splinting.
  • If conservative measures fail to correct the toe walking after about 12–24 months, surgical lengthening of the tendon is an option. The surgery is typically done under full anesthesia but if there are no issues, the child is released the same day. After the surgery, a below-the-knee walking cast is worn for six weeks and then an AFO is worn to protect the tendon for several months.

For toe walking which results from more serious neuro-muscular conditions, additional specialists may need to be consulted.

References
  1. "Toe Walking". Mayo Clinic. Archived from the original on 2007-06-03. Retrieved 2007-06-24.
  2. Babb A, Carlson WO (2008). "Idiopathic toe-walking". South Dakota Medicine. 61 (2): 53, 55–7. PMID 18432151.
  3. "Toe Walking". emedecine.com. Archived from the original on 2007-06-01. Retrieved 2007-06-07.
  4. "Equinus Deformity at Foot Associates of Central Texas, LLC". 2009. Archived from the original on 2013-12-08. Retrieved 2013-12-11.
  5. Sala DA, Shulman LH, Kennedy RF, Grant AD, Chu ML (1999). "Idiopathic toe-walking: a review" (PDF). Developmental Medicine & Child Neurology. 41 (12): 846–8. doi:10.1017/S0012162299001681. PMID 10619285.
  6. Geschwind DH (2009). "Advances in autism". Annual Review of Medicine. 60 (1): 367–80. doi:10.1146/annurev.med.60.053107.121225. PMC 3645857. PMID 19630577.
  7. Pomarino, David; Ramírez Llamas, Juliana; Pomarino, Andrea (2016). "Idiopathic Toe Walking Family Predisposition and Gender Distribution". Foot & Ankle Specialist. 9 (5): 417–422. doi:10.1177/1938640016656780. PMID 27370652.
  8. Pomarino, David; Ramírez Llamas, Juliana; Martin, Stephan; Pomarino, Andrea (16 January 2017). "Literature Review of Idiopathic Toe Walking: Etiology, Prevalence, Classification, and Treatment". Foot & Ankle Specialist. 10 (4): 337–342. doi:10.1177/1938640016687370. PMID 28092971.
  9. Pomarino, David; Ramírez Llamas, Juliana; Martin, Stephan; Pomarino, Andrea (16 January 2017). "Literature Review of Idiopathic Toe Walking: Etiology, Prevalence, Classification, and Treatment". Foot & Ankle Specialist. 10 (4): 337–342. doi:10.1177/1938640016687370. PMID 28092971.
  10. Pomarino, David; Ramírez Llamas, Juliana; Martin, Stephan; Pomarino, Andrea (16 January 2017). "Literature Review of Idiopathic Toe Walking: Etiology, Prevalence, Classification, and Treatment". Foot & Ankle Specialist. 10 (4): 337–342. doi:10.1177/1938640016687370. PMID 28092971.
  11. Kuijk, A; Kosters, R; Vugts, M; Geurts, A (2014). "Treatment for idiopathic toe walking: A systematic review of the literature". Journal of Rehabilitation Medicine. 46 (10): 945–957. doi:10.2340/16501977-1881. PMID 25223807.
  12. Pomarino, David; Ramírez Llamas, Juliana; Martin, Stephan; Pomarino, Andrea (16 January 2017). "Literature Review of Idiopathic Toe Walking: Etiology, Prevalence, Classification, and Treatment". Foot & Ankle Specialist. 10 (4): 337–342. doi:10.1177/1938640016687370. PMID 28092971.
  13. Pomarino, David; Ramírez Llamas, Juliana; Martin, Stephan; Pomarino, Andrea (16 January 2017). "Literature Review of Idiopathic Toe Walking: Etiology, Prevalence, Classification, and Treatment". Foot & Ankle Specialist. 10 (4): 337–342. doi:10.1177/1938640016687370. PMID 28092971.
  14. Kuijk, A; Kosters, R; Vugts, M; Geurts, A (2014). "Treatment for idiopathic toe walking: A systematic review of the literature". Journal of Rehabilitation Medicine. 46 (10): 945–957. doi:10.2340/16501977-1881. PMID 25223807.
  15. Hampton, DA, Hollander, Kw, Engsberg, JR (2003). "Equinus Deformity as a Compensatory Mechanism for Ankle Plantarflexor Weakness in Cerebral Palsy" (PDF). Journal of Applied Biomechanics. 19 (4): 325–339. doi:10.1123/jab.19.4.325. Retrieved 2013-12-11.CS1 maint: multiple names: authors list (link)
  16. Wren, T. A.; Do, K. P.; Kay, R. M. (2004). "Gastrocnemius and soleus lengths in cerebral palsy equinus gait: differences between children with and without static contracture and effects of gastrocnemius recession". Journal of Biomechanics. 37 (9): 1321–7. doi:10.1016/j.jbiomech.2003.12.035. PMID 15275839.
  17. "Toe Walking". orthoseek.com. Archived from the original on 2007-09-19. Retrieved 2007-06-07.
  18. "Toe Walking". mastersofpediatrics.com. Archived from the original on 2007-06-08. Retrieved 2007-06-24.
Classification
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