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 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]

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.^[7] 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.^[8]

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.^[9]

Treatment

For idiopathic toe walking in young children, doctors may prefer to watch and wait: the child may "outgrow" the condition.^[10] 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