Toe Walking

Toe Walking in Children

Toe walking, or persistent toe-heel walking, is a common observation in children, particularly toddlers learning to walk. In many cases, it is an isolated finding and a normal variation of gait that children outgrow. However, it can also be a sign of an underlying neuromuscular or developmental condition, and a thorough assessment is crucial to differentiate between these possibilities.

 

Aetiology and Clinical Assessment

Normal vs. Pathological Toe Walking

Toe walking is considered a normal variation up to the age of three years if it is an isolated finding and can be corrected. If it persists beyond this age or is accompanied by other symptoms, further investigation is warranted.

 

Causes and Associated Conditions

  • Idiopathic (Habitual) Toe Walking: This is the most common cause. The child simply has a habit of toe walking, with no other underlying issues. It can, however, lead to tightening of the Achilles tendon if it persists for a long time.

  • Neuromuscular Conditions:

    • Upper Motor Neuron (UMN) signs: Look for signs such as hypertonia, brisk reflexes, and clonus, which can indicate conditions like Cerebral Palsy, Hereditary Spastic Paraplegia, or evolving leukodystrophy.

    • Lower Motor Neuron (LMN) signs: Look for weakness, absent reflexes, muscle wasting, and foot deformities like pes cavus. These signs can be seen in conditions like Hereditary Sensory Motor Neuropathy (HSMN), such as Charcot-Marie-Tooth disease, or Spinal Cord Tethering.

  • Muscular Dystrophy: Duchenne Muscular Dystrophy can cause toe walking, often associated with bulky calves due to pseudohypertrophy.

  • Developmental Conditions: Toe walking is also more common in children with autism spectrum disorder and should prompt a broader assessment for other autistic behaviours.

 

Red Flags

It’s important to be aware of red flags that suggest an underlying pathological cause:

  • Toe walking that is not an isolated finding.

  • UMN or LMN signs.

  • Any foot deformity.

  • Associated developmental concerns, particularly social or communication difficulties.

Management

Management depends on the underlying cause.

 

Non-Surgical

  • Observation: For children under three with a simple, correctable toe walking gait, the primary management is observation and reassurance for the parents.

  • Physiotherapy: Regular stretches can help to prevent the Achilles tendon from tightening.

  • Orthotics: Splints or insoles can be used to encourage a more heel-to-toe walking pattern.

  • Botulinum Toxin: In some cases, botulinum toxin injections can be used to temporarily relax the calf muscles to aid in stretching and gait training.

 

Surgical

  • Surgical intervention is considered when non-surgical treatments fail and the Achilles tendon has become significantly contracted.

  • Procedures: Surgical options include Achilles tendon lengthening or tendon transfer to improve ankle range of motion.