Orthopaedic Surgery - Toe Walking

Basics

Toe walking describes a gait pattern in which a child walks predominantly on the:

Forefoot

with limited or absent:

Heel strike.

Idiopathic toe walking is relatively common in:

Toddlers and young children.

Idiopathic Toe Walking

Many children who toe walk have no identifiable:

Neurologic

Orthopaedic

or

Neuromuscular disorder.

When other causes have been excluded, the condition is termed:

Idiopathic toe walking.

Achilles Tendon Tightness

Some children develop or have an associated shortened:

Achilles tendon

or tight:

Gastrocnemius-soleus complex.

This may restrict:

Ankle dorsiflexion

and reinforce the toe-walking pattern.

Natural History

Some children spontaneously develop a normal:

Heel-toe gait

as they:

Grow.

Persistent Toe Walking

Persistent, nearly exclusive toe walking beyond approximately:

5 years of age

should prompt careful assessment for an underlying:

Neurologic or neuromuscular disorder.

Epidemiology

Toe walking is usually first noticed when the child begins:

Independent walking.

Incidence

Transient toe walking is:

Common

during early childhood.

Sex

Boys and girls are affected approximately:

Equally.

Risk Factors

Potential associations include:

Positive family history

Premature birth

Low Apgar score

and other:

Neuromotor abnormalities.

Genetics

A familial tendency is relatively common.

Historical studies have reported a positive family history in up to approximately:

50% of patients.

Etiology

Idiopathic toe walking is thought to involve a combination of:

Neuromotor patterning

and, in some children,

Achilles tendon shortening.

Diagnosis

Idiopathic toe walking is primarily a:

Clinical diagnosis.

Importantly, it is a:

Diagnosis of exclusion.

A neurologic, neuromuscular, or structural cause should be excluded before labeling the gait:

Idiopathic.

History

The clinician should establish:

When toe walking began

Whether it has always been present

and whether the child can voluntarily walk with:

Heel strike.

Developmental History

Ask about:

Birth history

Prematurity

Developmental milestones

and any history of:

Motor delay.

Family History

Ask whether parents or siblings had:

Toe walking

Neuromuscular disease

or abnormal:

Gait development.

New-Onset Toe Walking

Toe walking that begins after a period of normal:

Heel-toe gait

is more concerning than toe walking present from the onset of:

Walking.

This pattern warrants evaluation for an acquired:

Neurologic

Spinal

or

Musculoskeletal cause.

Physical Examination

The child should ideally be examined wearing:

Shorts

with the lower extremities fully visible.

Gait Observation

Observe the feet throughout:

Standing

Walking

and, when possible,

Running.

Heel Strike

Determine whether the child demonstrates:

Heel strike

at any point during the gait cycle.

Voluntary Correction

Ask the child to attempt:

Heel-toe walking.

The ability to correct the gait voluntarily may support a diagnosis of:

Idiopathic toe walking.

Neurologic Examination

A complete neurologic examination should assess for:

Spasticity

Weakness

Hyperreflexia

Abnormal tone

and other signs of:

Neuromuscular disease.

Ankle Range of Motion

Measure ankle:

Dorsiflexion

with the knee:

Flexed

and

Extended.

Silfverskiöld Principle

Comparing ankle dorsiflexion with the knee flexed and extended helps distinguish:

Gastrocnemius tightness

from combined:

Gastrocnemius-soleus contracture.

Calf Examination

Palpate and inspect the calf for:

Atrophy

Abnormal masses

or

Pseudohypertrophy.

Pseudohypertrophy

Prominent calf enlargement can be a clue to conditions such as:

Muscular dystrophy.

Hamstrings and Adductors

Examine the:

Hamstrings

and

Hip adductors

for abnormal:

Tightness.

This may suggest an underlying:

Neurologic disorder.

Passive and Active Motion

Document both:

Passive

and

Active ankle range of motion.

Testing

Additional investigations are usually unnecessary when the history and physical examination are entirely consistent with:

Idiopathic toe walking.

Neuromuscular Testing

When muscular dystrophy or another myopathic process is suspected, testing may include:

Creatine kinase

and selected:

Genetic studies.

Muscle biopsy is now reserved for selected cases when the diagnosis remains:

Uncertain.

Imaging

MRI of the spine may be appropriate when examination suggests:

Spinal cord pathology

Tethered cord

or another cause of:

Spasticity.

Differential Diagnosis

Important conditions to exclude include:

Cerebral palsy

Muscular dystrophy

Tethered cord syndrome

Hereditary spastic paraplegia

Charcot-Marie-Tooth disease

and

Arthrogryposis.

Cerebral Palsy

Toe walking from cerebral palsy is often accompanied by:

Spasticity

Hyperreflexia

and other abnormalities of:

Motor control.

Muscular Dystrophy

Muscular dystrophy may produce:

Proximal weakness

Gower sign

and

Calf pseudohypertrophy.

Tethered Cord

Tethered cord or other spinal pathology may present with:

New gait abnormality

Weakness

Spasticity

or abnormalities of:

Bladder or bowel function.

Charcot-Marie-Tooth Disease

Charcot-Marie-Tooth disease may cause:

Distal weakness

Pes cavus

and altered:

Gait mechanics.

Treatment

Treatment depends on:

Age

Severity

Ankle range of motion

and whether the child can voluntarily achieve:

Heel-toe gait.

General Measures

Initial management usually consists of:

Observation

Stretching

and

Encouragement of normal heel-toe walking.

Mild Cases

Young children with:

Flexible ankles

and no underlying disorder may simply be:

Observed.

Stretching

Regular stretching of the:

Gastrocnemius-soleus complex

may help preserve or improve:

Ankle dorsiflexion.

Orthotics

Orthotic devices may help guide gait in selected children but, when used alone, do not reliably correct persistent:

Toe walking.

Serial Casting

Serial casting may be used when ankle dorsiflexion is:

Restricted.

Casting Technique

The ankle is gradually positioned into increasing:

Dorsiflexion.

The goal is often to achieve at least approximately:

10° of dorsiflexion

while facilitating development of a:

Heel-toe gait.

Cast Changes

Casts are typically changed approximately:

Weekly

until the desired:

Range of motion

is obtained.

Night Bracing

Night splints holding the ankle in:

Dorsiflexion

may help preserve gains achieved through:

Casting

or

Surgery.

Physical Therapy

Physical therapy may be helpful in children with:

Mild or flexible toe walking.

Range-of-Motion Exercises

Therapy may include:

Passive ankle stretching

and

Active dorsiflexion exercises.

Gait Training

Children who can dorsiflex beyond neutral may practice:

Heel walking

and

Heel-toe gait.

This can reinforce a more typical:

Motor pattern.

Strengthening

Therapy may also focus on strengthening the:

Ankle dorsiflexors

and improving:

Balance and gait control.

Surgery

Surgery is considered when conservative measures fail and persistent:

Achilles contracture

prevents normal:

Heel strike.

Achilles Lengthening

The principal operative procedure is:

Achilles tendon lengthening.

Techniques

Lengthening may be performed using:

Percutaneous

or

Open techniques.

A:

Z-lengthening

is one traditional approach.

Timing

Surgery is generally considered when a child has persistent toe walking approaching the:

School-age years

and fails to develop a functional:

Heel-toe gait.

Goal of Surgery

The objective is to restore sufficient:

Ankle dorsiflexion

to permit normal:

Heel contact during gait.

Avoiding Overlengthening

Excessive Achilles lengthening must be avoided because it may produce:

Weak plantarflexion

and a:

Calcaneal or crouched gait.

Referral

Referral to a pediatric orthopaedic specialist is appropriate when:

Toe walking begins after previously normal gait

or when the child fails to improve by:

Kindergarten or early school age.

Neurologic Referral

Neurology or other specialist evaluation may be required when examination suggests:

Spasticity

Weakness

Developmental delay

or another:

Neuromuscular disorder.

Follow-Up

Children should be reassessed for changes in:

Gait pattern

Ankle dorsiflexion

and

Achilles tendon flexibility.

Prognosis

Many children with idiopathic toe walking spontaneously develop a normal:

Heel-toe gait.

Early Resolution

A substantial number improve by approximately:

3 years of age.

Persistent Toe Walking

Persistent toe walking into adolescence or adulthood may result in:

Metatarsal calluses

Achilles contracture

and impaired:

Balance.

Complications

Important complications include:

Failure to recognize an underlying neurologic disorder

Recurrence after treatment

and complications of:

Achilles lengthening.

Missed Neurologic Diagnosis

The most important diagnostic complication is incorrectly labeling pathologic toe walking as:

Idiopathic.

Recurrence

Toe walking may recur after:

Casting

or

Surgery

particularly if the underlying gait pattern persists.

Achilles Overlengthening

Excessive surgical lengthening can produce:

Plantarflexion weakness

and abnormal:

Calcaneal or crouch gait.

Patient Monitoring

Follow-up should document:

Heel strike

Ankle dorsiflexion

Gait symmetry

Muscle strength

and any emerging:

Neurologic findings.

Clinical Summary

Typical patient: Toddler who has walked on the toes since beginning independent ambulation but otherwise has normal development and neurologic examination.

Key diagnostic principle: Idiopathic toe walking is a diagnosis of exclusion; cerebral palsy, muscular dystrophy, tethered cord, hereditary spastic disorders, and peripheral neuropathy must be considered.

Key examination: Observe gait and measure ankle dorsiflexion with the knee both flexed and extended while performing a complete neurologic examination.

Testing: Usually unnecessary unless the examination suggests a neurologic, spinal, or myopathic disorder.

Natural history: Many children improve spontaneously, particularly by about 3 years of age.

Initial treatment: Observation, Achilles stretching, gait training, and selected physical therapy.

Persistent contracture: Serial casting and night bracing may improve ankle dorsiflexion.

Surgery: Achilles lengthening is reserved for persistent toe walking with fixed equinus that fails conservative management.

Red flag: New-onset toe walking after a previously normal heel-toe gait warrants further investigation.

Key Principle

Idiopathic toe walking is a common childhood gait pattern characterized by forefoot walking without an identifiable neurologic or orthopaedic cause.

It is a:

Diagnosis of exclusion.

Persistent toe walking beyond approximately:

5 years of age, new-onset toe walking, weakness, spasticity, abnormal reflexes, or developmental abnormalities should prompt evaluation for:

Neuromuscular or spinal disease.

Children with flexible ankles often improve with:

Observation, stretching, and gait retraining.

Persistent equinus may be treated with:

Serial casting and night bracing, while:

Achilles tendon lengthening

is reserved for selected children with fixed contracture and persistent functional toe walking.