Idiopathic toe walking is a term used to define a gait in which a person walks with a toe‐toe gait pattern without any known correlated etiology
idiopathic toe walking is when your child continues to walk on their tiptoes beyond three years of age
Toe walking refers to a walking pattern in which a child walks on the balls of their feet and there is no contact between the heels and the ground. There are many medical reasons for this type of walking pattern. This handout is about a specific type of toe walking called idiopathic toe walking.
Some children with idiopathic toe walking are able to walk with their feet flat when asked to do so. When these children wear shoes, they might not walk on their toes. Their toe walking is often exaggerated when they walk bare-footed from one room to another or when they walk on surfaces that have increased tactile sensations (carpet, cold tile, grass). These children typically do not have tightness in their Achilles
Key Points :
•Idiopathic toe walking is when a child continues to walk on their tiptoes beyond three years of age.
•Idiopathic toe walking can lead to tight calf muscles and decreased movement of the ankles.
•Treatment for children younger than six years of age include calf stretches, Achilles tendon stretches and sits to stand exercises.
•Treatment for children six years of age and older includes calf stretches and other exercises including marching on the spot, walking uphill and on uneven surfaces, heel walking and squats.
Features of idiopathic toe walking
•Although we do not really know why some children prefer to walk on their toes, we do know that
idiopathic toe walkers:
•walk on tiptoes on both sides
•are constantly balancing on their toes
•are physically able to keep up with other children their age
•walk with straight knees
•will often be able to stand with their feet flat on the ground
•often have a family history of toe walking
The weight-bearing skeleton will adapt the form to function, especially in young children
•Hypertrophy of the talar neck
•Underdeveloped calcaneus
Pain
•Calf pain and increased calluses and corns on balls of feet.
Soft tissue problems
•Tendency towards pes cavus
•Fixed Achilles tendon tightness and calf contractures
Neuro-Developmental impairment
•Strong evidence for increase ankle sprains with gastroc tightness
•Balance?
•Vestibular seeking?
•Back pain?
What causes idiopathic toe walking?
• Tactile processing: increased response to touch sensations
• Altered proprioceptive processing (sensing the body’s position in space)
• Vestibular processing (maintaining balance)
• Visual processing
• Flexibility of leg and foot muscles
• overall body strength
• Family history: parents or siblings who have a history of toe walking
Presentation
•Patient walks with a bilateral toe to toe gait intermittently or consistently
•They do not typically present with pain
•They may or may not have tight heel cords with decreased ankle dorsiflexion and possibly not be able to stand in plantigrade position if have significant equinas contractures
Diagnosis
•Past Medical/Surgical history to include birth history, developmental milestone achievement, evaluation of family history for progressive neuromuscular conditions,
•Thorough history with specific attention to musculoskeletal and
neurologic symptoms especially bowel/bladder pattern difficulties
Diagnostic_Tests
•if patient is a chronic toe‐toe walker‐with abnormal neurologic exam and/or abnormal bowel/bladder function recommend getting an MRI of the brain/spine
•If positive Gowers sign obtain CK blood level
•Consider MRI of brain and spine and referral to the orthopaedic surgeon, even if no neurologic signs/symptoms, if despite casting, continues to toe walk and presents with significant equinus contractures
Physical_examination
•Specific attention to musculoskeletal and neurologic exams.
•In regard to the musculoskeletal exam, make sure to evaluate ankle motion and gait.
•In regard to the neurologic exam, make sure to specifically check for the following: DTRs, muscle wasting, Babinski, clonus, hypertonia, Gowers sign, and signs of spinal dysraphism (spinal dimple, hairy patch).
Examination:
ROM
Strength
Posture/Alignment
Balance
Gait
Sensory processing screening
Evaluation:
•Ankle DF with knee ext
•Hamstring moderately tight
•Constant toe walking
•Can stand with heels down with knee hyperextension, hip flex, and out-toeing; unable to hold static standing on toes
•Poor single leg balance, unable to squat, hesitant downstairs,
Can idiopathic toe walking be treated
For young children with idiopathic toe walking without Achilles’ tendon contractures, watching and waiting is an option. Some younger children benefit from physical therapy where they are taught how to stretch their legs, feet and toes. Night-time bracing with plastic orthotics may be helpful. In some cases, idiopathic toe walking may resolve on its own. For preschool and older children with idiopathic toe walking with Achilles’ tendon contractures, some of these treatment options may be needed
Physical Therapy: This involves stretching, strengthening, gait training, and home exercise.
Occupational Therapy: This involves helping your child learn sensory integration strategies.
Orthotics: Plastic splints can be worn on the feet and ankles during the night to maintain the stretch/flexibility of the Achilles’ tendons. Occasionally, they are also worn during the day.
Serial Casting:
This involves a series of casts to stretch your child’s Achilles’ tendons.
Orthopedic_Surgery: This involves a surgical procedure to lengthen the heel cord (Achilles’ tendon). This is done only in children over the age of 4 to 5 years in whom the other treatment interventions have been unsuccessful in stretching the Achilles’ tendons.
Stretching
Night splinting
Terex/Strengthening
Joint mobilizations
Balance training (especially standing balance and posterior weight shifting)
Gait training/Treadmill training
Motor Control/Motor Learning Strategies
Taping (if required )
Orthotics (AFOs or ITW inhibiting)
Serial casting
Shoe modifications
Sensory strategies
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