Toe walking explained

Toe walking
Field:	Pediatrics

Toe walking is a term describing a type of walking style. Toe walking is when a person walks on their toes or the ball of their foot, without putting much or any weight on the heel or any other part of the foot.^[1] Toe walking in toddlers is common. Children who toe walk as toddlers commonly adopt a heel-toe walking pattern as they grow older. If a child continues to walk on their toes past the age of three, or cannot get their heels to the ground at all, they should be examined by a health professional who is experienced in assessing children's walking.^[2]

Toe walking can be associated with a number of health conditions, or have an unknown reason. When no medical reason for toe walking and no underlying condition can be identified, health professionals will commonly refer to it as "idiopathic" toe walking. This is not a formal or recognized diagnosis; rather, it is simply a term indicating that there is no identifiable reason or cause for the toe walking and that time. The child may have a diagnosis that becomes more apparent as they grow or never have a diagnosis that causes the toe walking.^[3] Idiopathic toe walking should only be considered after all other conditions have been excluded. ^[4]

Other causes for toe walking include a congenital short Achilles tendon, muscle spasticity (commonly associated with cerebral palsy) or genetic diseases muscle disease such as Duchenne muscular dystrophy. Toe walking may also be caused by a bone block located at the ankle which prevents the ankle from moving. This may be as the result of trauma or arthritis.^[5] Toe walking may also be one way of accommodating a separate condition, foot drop. Persistent toe walking in children is also associated with developmental disabilities, such as autism.^{[6] [7]} In a recent study, 68% of children with an Autism Spectrum Disorder report experiencing walking changes.^{[8] [9]} Those with sensitive nervous systems, such as people with Autism Spectrum Disorder, Sensory Prosessing Disorder, or giftedness are also reported to be prone to toe walking.

It is estimated that 5% of healthy children have no reason for their toe walking (idiopathic toe walking).^[10] Idiopathic toe walking has also been observed more in males than females when very large groups of children with toe walking are observed. One study looked for a family history of toe walking, and found a connection with family members all toe walking with no medical reason (idiopathic toe walking). This means there may be a genetic link with idiopathic toe walking.^[11] Idiopathic toe walking spontaneously disappears over the years in the majority of cases and is most often not associated with a motor or cognitive issue.^[12]

Cause

Idiopathic toe walking is always bilateral and has no orthopedic or neurological cause. It is diagnosed after if it continues past the age of three.^[13] In this condition, children are able to voluntarily walk with the typical heel-toe pattern, but prefer to walk on their tip toes. 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.^{[14] [15]} It is thought to be related to sensory processing challenges.^{[16] [17]} Two classifications of idiopathic toe walking have been established. The Alvarez's classification identifies the severity of the toe walking based upon kinematics and ankle rockers.^[18] 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.^[19]

Cerebral palsy

Studies have been performed to determine the source of the association between toe walking and cerebral palsy. 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.^[20] In people who have cerebral palsy and toe walk, there is greater plantarflexion force required for normal heel-to-toe walking than for toe walking. When typically developing children are tasked to perform different types of toe walking, their toe walking could not reduce the force to the levels that children who toe walking with cerebral palsy have when they walk. This suggests that toe walking associated with cerebral palsy may be due to abnormally weakened plantarflexion that can only manage toe walking.^[21]

GLUT1 Deficiency Syndrome

Toe walking is a symptom in those with GLUT1 deficiency Syndrome.^[22]

Diagnosis

There are many health professionals who assess and treat toe walking. Family physicians, neurologists, orthopaedic surgeons, pediatricians, physical therapists, physiotherapists and podiatrists are all commonly consulted. Treatment will depend on the cause of the condition.^[23]

Treatment

For idiopathic toe walking in young children, health professionals may prefer to watch and wait: as the child may "outgrow" the toe walking with time.^[24] There are limited treatments that demonstrate long term walking change. Many treatments instead focus on any tightness in the calf muscles that can be associated with the toe walking.^{[25] [26]} Common treatments for idiopathic toe walking can include:

• Wearing a brace, splint or type of orthoses either during the day, night or both. The brace limits the ability of the child to walk on their toes and may stretch muscle and tendon at the back of the leg. One type of orthoses commonly used are an AFO (ankle-foot orthoses).
• Serial casting, where the leg is cast with the calf muscle stretched. The cast is changed weekly with progressive stretching. Sometimes, these casts are not be changed weekly and instead every 2–3 weeks.
• Botox therapy may be used to paralyze the calf muscles to reduce the opposite of the muscles to work harder. This may be used with serial casting or splinting, however, one small study has shown this has limited impact.
• If conservative (non-surgical) measures do not help with changing the walking or making the calf muscles longer and correcting the toe walking after about 12–24 months, surgical lengthening of the tendon is an option. The surgery is typically done under full anaesthesia but if there are no issues, the child is released the same day. After the surgery, a below-the-knee walking cast is often worn for six weeks and then an AFO is worn to protect the tendon for several months.

For toe walking which results from other medical conditions, additional specialists may need to be consulted.

Notes and References

1. Kuijk . A . Kosters . R . Vugts . M . Geurts . A . Treatment for idiopathic toe walking: A systematic review of the literature . Journal of Rehabilitation Medicine . 2014 . 46 . 10 . 945–957 . 10.2340/16501977-1881. 25223807 . free .
2. Web site: Toe Walking . Mayo Clinic . 2007-06-24 . live . https://web.archive.org/web/20070603173311/http://www.mayoclinic.com/health/toe-walking/AN01253 . 2007-06-03 .
3. South Dakota Medicine . 2008 . 61 . 2 . 53, 55–7 . Idiopathic toe-walking . Babb A, Carlson WO . 18432151.
4. Williams . C . Tinley. P. Curtin. M. The Toe Walking Tool: a novel method for assessing idiopathic toe walking children . Gait & Posture . 2010 . 32 . 4 . 508–11 . 10.1016/j.gaitpost.2010.07.011 . 20692159.
5. Web site: Equinus Deformity at Foot Associates of Central Texas, LLC . 2009 . 2013-12-11 . live . https://web.archive.org/web/20131208085429/http://whymyfoothurts.com/conditions/equinus.html . 2013-12-08 .
6. Developmental Medicine & Child Neurology . 1999 . 41 . 12 . 846–8 . Idiopathic toe-walking: a review . Sala DA, Shulman LH, Kennedy RF, Grant AD, Chu ML . 10619285 . PDF . 10.1111/j.1469-8749.1999.tb00553.x .
7. Geschwind DH . Advances in autism . . 60 . 1. 367–80 . 2009 . 19630577 . 10.1146/annurev.med.60.053107.121225 . 3645857.
8. Shetreat-Klein . Maya . Shinnar . Shlomo . Rapin . Isabelle . Abnormalities of joint mobility and gait in children with autism spectrum disorders . Brain and Development . February 2014 . 36 . 2 . 91–96 . 10.1016/j.braindev.2012.02.005. 22401670 . 27287327 .
9. Barkocy . Marybeth . Schilz . Jodi . Heimerl . Sandra . Chee . Madeleine . Valdez . Meghan . Redmond . Kelly . The Effectiveness of Serial Casting and Ankle Foot Orthoses in Treating Toe Walking in Children With Autism Spectrum Disorder . Pediatric Physical Therapy . April 2021 . 33 . 2 . 83–90 . 10.1097/PEP.0000000000000784. 33724238 . 232242384 .
10. Engstrom . P . Tedroff . K . The prevalence and course of idiopathic toe-walking in 5-year-old children . Pediatrics . 2012 . 130 . 2 . 279–84 . 10.1542/peds.2012-0225 . 22826572. 2915651 .
11. Idiopathic Toe Walking Family Predisposition and Gender Distribution. Foot & Ankle Specialist. 9. 5. 417–422. 10.1177/1938640016656780. 27370652. 2016. Pomarino. David. Ramírez Llamas. Juliana. Pomarino. Andrea. 1160638.
12. Web site: Votre enfant marche sur la pointe des pieds? Pas de quoi s'inquiéter . 2023-07-20 . naitreetgrandir.com . fr.
13. Stricker . S . Idiopathic toe walking: a comparison of treatment methods . Pediatr Orthoped . 1998 . 18 . 3 . 289–93 . 10.1097/00004694-199805000-00003. 9600550 .
14. Williams . C . Tinley. P. Curtin. M. The Toe Walking Tool: a novel method for assessing idiopathic toe walking children . Gait & Posture . 2010 . 32 . 4 . 508–11 . 10.1016/j.gaitpost.2010.07.011 . 20692159.
15. Kuijk. A. Kosters. R. Vugts. M. Geurts. A. Treatment for idiopathic toe walking: A systematic review of the literature. Journal of Rehabilitation Medicine. 2014. 46. 10. 945–957. 10.2340/16501977-1881. 25223807. free.
16. Fanchiang . H . Geil . M . Wu . J . Ajisafe . T . The Effects of Walking Surface on the Gait Pattern of Children With Idiopathic Toe Walking . Journal of Child Neurology. 2016 . 31 . 7 . 858–863 . 10.1177/0883073815624760. 26733505 . 5526538 . free .
17. Williams . C . Tinley . P . Curtin . M . Wakefield . S . Nielson . S . Is Idiopathic Toe Walking Really Idiopathic? The Motor Skills and Sensory Processing Abilities Associated With Idiopathic Toe Walking Gait . Journal of Child Neurology . 2014 . 29 . 1 . 71–78 . 10.1177/0883073812470001. 23349518 . 5696959 .
18. Alvarez. Christine. De Vera. Mary. Beauchamp. Richard. Ward. Richard. Black. Alac. Classification of idiopathic toe walking based on gait analysis: development and application of the ITW severity classification. Gait & Posture. 2007. 26. 3. 428–435. 10.1016/j.gaitpost.2006.10.011. 17161602.
19. Pomarino. David. Ramírez Llamas. Juliana. Martin. Stephan. Pomarino. Andrea. Literature Review of Idiopathic Toe Walking: Etiology, Prevalence, Classification, and Treatment. Foot & Ankle Specialist. 16 January 2017. 10. 4. 337–342. 10.1177/1938640016687370. 28092971. 3389265.
20. Journal of Applied Biomechanics . 2003 . 19 . 4 . 325–339 . Equinus Deformity as a Compensatory Mechanism for Ankle Plantarflexor Weakness in Cerebral Palsy . Hampton, DA, Hollander, Kw, Engsberg, JR . 2013-12-11. 10.1123/jab.19.4.325 .
21. Journal of Biomechanics . 2004 . 1321–7 . Gastrocnemius and soleus lengths in cerebral palsy equinus gait: differences between children with and without static contracture and effects of gastrocnemius recession . 15275839 . 10.1016/j.jbiomech.2003.12.035 . 37 . 9. Wren . T. A. . Do . K. P. . Kay . R. M. .
22. Sandu C, Burloiu CM, Barca DG, Magureanu SA, Craiu DC. Ketogenic Diet in Patients with GLUT1 Deficiency Syndrome . Maedica (Bucur) . 2019 . 14 . 2 . 93–97 . 31523287 . 10.26574/maedica.2019.14.2.93 . 31 January 2024 . 6709387 .
23. Web site: Toe Walking . orthoseek.com . 2007-06-07 . live . https://web.archive.org/web/20070919235923/http://www.orthoseek.com/articles/toewalk.html . 2007-09-19 .
24. Web site: Toe Walking . mastersofpediatrics.com . 2007-06-24 . dead . https://web.archive.org/web/20070608193953/http://www.mastersofpediatrics.com/cme/cme2005/lecture30_1.asp . 2007-06-08 .
25. Caserta . A . Pacey . V . Fahey . M . Gray . K . Engelbert . R . Williams . C . Interventions for idiopathic toe walking . Cochrane Database of Systematic Reviews . 2019 . 2019 . 10 . CD012363 . 10.1002/14651858.CD012363.pub2. 31587271 . 6778693 .
26. Web site: Toe Walking . emedecine.com . 2007-06-07 . live . https://web.archive.org/web/20070601015552/http://www.emedicine.com/orthoped/topic451.htm . 2007-06-01 .