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Toe walking

Toe walking is a pattern of walking in which a child walks on balls of his or her feet, with no contact between the heels and ground. Toe walking is common in children who are learning to walk. After the age of two, however, most children outgrow toe walking and begin to walk with a normal heel-to-toe pattern.

In very rare cases, continuing to toe walk after age two may be a sign of an underlying medical condition. In the vast majority of cases, however, persistent toe walking is “idiopathic,” which means that the exact cause is not known. Older children who continue to toe walk may do so out of habit or because the muscles and tendons in their calves have become tighter over time.

Symptoms

Most young children who walk on their toes are able to walk flat-footed when asked to do so. However, many older children who continue to toe walk (usually those over the age of five) are not able to walk with their heels down. These children may complain about problems wearing shoes or participating in sports or recreational activities that involve wearing roller skates or ice skates. Some children who toe walk usually have no specific complaints or pain, but their parents are concerned about the impact their walking may have on their future function as teenagers and adults.

Causes

In the vast majority of children, toe walking is “idiopathic”. When these children are evaluated by a doctor, their physical exams and neurological tests are usually normal. Toe walking may also run in families.

In a smaller number of cases, persistent toe walking can be a sign of an underlying medical condition, such as: cerebral palsy, muscular dystrophy or a spinal cord abnormality.

Although children with autism-related conditions toe walk more frequently than children who are developing normally, there is no direct link between the two conditions, and their toe walking may be sensory-related.

In some children who toe walk, the muscles and tendon combination in the calf may be shorter at birth, or may shorten over time, which prevents the child from touching his or her heels to the ground and walking flat-footed.

When to see a doctor

Typically, toe walking is a habit that develops when a child learns to walk. If your child is still toe walking after age two, it’s time to talk to your doctor about it. Make an appointment sooner if your child also has tight leg muscles, stiffness in the Achilles tendon or a lack of muscle co-ordination.

Diagnosis

Toe walking can be observed during a physical exam. In some cases, the doctor will take a detailed history, watch the child walk and perform a physical exam.

If the doctor suspects cerebral palsy or autism, a neurological exam or testing for developmental delays may be done. Some simple neurological tests will help find out if there is any abnormality in the child’s nervous system that could be contributing to the toe walking. The exam will be tailored to the child’s age, developmental level and ability to co-operate.

During the exam, the doctor will assess if there is any contracture or excessive tightness of the muscles in the arms or legs, check the strength of the major muscles, check the child’s reflexes and test sensation, or feeling, in the arms and legs.

Other tests like an electromyography (EMG) – that measures the electrical activity in the affected nerve or muscle – may be ordered, but other tests such as X-rays, CT or MRI scans are not usually ordered.

Treatment

Treatment for toe walking depends on a number of factors, including the age of the child and whether the child is able to walk flat-footed. If the child is toe walking out of habit, no treatment is needed. She or he is very likely to outgrow the habit. The doctor will simply monitor the child’s gait during office visits.

If a physical problem is contributing to toe walking, treatment options may include non-surgical treatment for children who are two to five years old and able to walk flat-footed. Initial treatment is always nonsurgical. This may include:

Serial casting: Your doctor may apply a series of short leg walking casts to help progressively stretch and lengthen the muscles and tendons in the calf and break the toe-walking habit. Serial casting is usually performed over a period of several weeks.

Bracing: Wearing an ankle-foot orthosis (AFO) can help stretch and lengthen muscles and tendons. An AFO is a plastic brace that extends up the back of the lower leg and holds the foot at a 90-degree angle. Typically, bracing is performed for a longer period of time than casting (months rather than weeks).

Botox therapy: For certain patients – usually those with a neurologic abnormality that leads to increased muscle tone – an injection of botulinum A toxin (Botox) may also be given to temporarily weaken the calf muscles. This will allow the muscles to stretch more easily during casting or bracing.

Surgery

If conservative treatments fail, the doctor may recommend surgery to lengthen the muscles or tendons at the back of the lower leg or reposition the bones in the foot, which will allow the child to walk flat-footed. Surgery is usually performed after the age of five if the toe walking continues.

Complications

Persistent toe walking can increase a child’s risk of falling, pain in the foot, deformity and also result in a social stigma.

• For more information email foothealth242@gmail.com or visit www.foothealth.org, apma.org or orthoinfo.aaos.org. To see a podiatrist, visit Bahamas Foot Centre on Rosetta Street, telephone 325-2996 or Bahamas Surgical Associates on Albury Lane, telephone 394-5820. On Grand Bahama, call or visit Lucayan Medical Centre on East Sunrise Highway, or telephone 373-7400 for an appointment.

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