Toe walking is a gait abnormality where the heels do not contact the ground during walking, and the forefoot bears most of the body weight throughout the gait cycle. It is defined by the absence of heel strike in the initial stance phase and incomplete foot contact during the rest of the gait.
Toe walking can result from various causes, ranging from habitual behavior to serious neuromuscular conditions. The most common form is idiopathic toe walking (ITW), a diagnosis made when no underlying medical cause is found. In contrast, non-idiopathic toe walking (non-ITW) is linked to identifiable conditions, often neurological or muscular in origin, and requires careful diagnosis to guide treatment and assess the likelihood of recurrence.
While toe walking is typical in toddlers learning to walk, most children adopt a heel-to-toe gait by around 22 months. If the pattern continues beyond age 2, further assessment is recommended.
Treatment is tailored to the individual, considering age, severity, and cause. Options range from watchful waiting to surgical interventions. One common surgical treatment is Achilles tendon tenotomy, a long-established orthopedic procedure.
Epidemiology
The true prevalence of idiopathic toe walking (ITW) is unclear due to underreporting, but studies suggest it affects 2% to 24% of children, depending on the population studied. Higher rates are observed in children with developmental or neuropsychiatric conditions, such as autism, ADHD, and language disorders. For instance, up to 20% of children with autism exhibit toe walking.
A 2016 study by Baber et al found that children with ITW were more likely to be born prematurely, have lower birth weights, and require neonatal intensive care. Though assisted births were more common in medical cases, no strong link was found with ITW alone. Delivery complications were more frequent among ITW cases, suggesting a possible connection to motor development issues.
Non-idiopathic toe walking is commonly associated with cerebral palsy (CP) and Duchenne muscular dystrophy (DMD). In CP, toe walking varies by severity and affects fewer than half of patients. In DMD, toe walking develops over time due to muscle degeneration and tendon contractures.
Anatomy
Pathophysiology
The underlying mechanisms of idiopathic toe walking (ITW) are not fully understood, but it is thought to involve subtle sensory processing issues, possibly linked to vestibular dysfunction or heightened tactile sensitivity. However, scientific evidence supporting these theories is limited.
There is some indication of a genetic basis for ITW, as many case series report a positive family history. Originally, ITW was associated with congenital shortening of the Achilles tendon, leading to ankle equinus and toe walking. However, later studies have shown that not all children with ITW have structural abnormalities; some are capable of walking flat-footed and may exhibit a habitual or voluntary toe-walking pattern.
Non-idiopathic toe walking can result from neurologic or muscular causes, most notably cerebral palsy (CP) and Duchenne muscular dystrophy (DMD). In CP, toe walking usually arises from lower-limb spasticity. This can cause ankle equinus due to slow growth of spastic muscles and, additionally, result from compensatory toe walking when hip and knee flexion prevent stable upright posture.
In DMD, progressive muscle degeneration weakens the foot dorsiflexors more than the plantarflexors, and toe walking may develop as a compensatory strategy. As the quadriceps weaken, patients lose knee extension strength, leading to a flexed knee posture. Walking on the forefoot creates a mechanical advantage that helps stabilize the knee during gait.
Etiology
Toe walking can be classified into two main types: idiopathic (ITW) and non-idiopathic. Non-ITW is linked to identifiable medical conditions, including neurological disorders (such as spina bifida, cerebral palsy, tethered cord, and diastematomyelia), muscle-related conditions (like congenital muscular dystrophy), and structural issues such as differences in limb length. Rarely, toe walking may occur due to temporary conditions, such as viral myositis, as reported in an otherwise healthy child.
Idiopathic toe walking is the most frequently observed form, characterized by the absence of an underlying medical cause. Initially described in 1967 as “habitual toe walking” or due to a “congenital short Achilles tendon,” ITW is diagnosed only after other causes are ruled out. It typically presents as bilateral toe walking in children over the age of two, with or without tightness in the Achilles tendon.
Genetics
Prognostic Factors
Toe walking can be classified into two main types: idiopathic (ITW) and non-idiopathic. Non-ITW is linked to identifiable medical conditions, including neurological disorders (such as spina bifida, cerebral palsy, tethered cord, and diastematomyelia), muscle-related conditions (like congenital muscular dystrophy), and structural issues such as differences in limb length. Rarely, toe walking may occur due to temporary conditions, such as viral myositis, as reported in an otherwise healthy child.
Idiopathic toe walking is the most frequently observed form, characterized by the absence of an underlying medical cause. Initially described in 1967 as “habitual toe walking” or due to a “congenital short Achilles tendon,” ITW is diagnosed only after other causes are ruled out. It typically presents as bilateral toe walking in children over the age of two, with or without tightness in the Achilles tendon.
Clinical History
Age Group:
Commonly observed in toddlers learning to walk (normal up to age 2 years).
Persistent toe walking beyond age 2 warrants further evaluation.
Most children with idiopathic toe walking (ITW) present between 2–5 years.
Non-idiopathic toe walking may present earlier or later depending on the underlying disorder.
Physical Examination
The physical examination of a child with toe walking aims to exclude known neurological, muscular, or orthopedic causes before diagnosing idiopathic toe walking (ITW). It begins with observing the child’s overall appearance and gait, followed by inspection of the spine and lower limbs for abnormalities such as leg-length discrepancy, muscle asymmetry, or foot deformities. Neurologic assessment includes evaluating muscle strength through functional tasks like rising from the floor or climbing onto an exam table, along with reflexes, tone, and response to stimuli. Joint range of motion, especially at the ankle, should be tested using the Silfverskiöld test, with dorsiflexion assessed in a neutral heel position. In ITW, findings are typically normal except for bilateral toe walking and possible heel-cord tightness. Asymmetry in toe walking suggests an alternative diagnosis.
Age group
Associated comorbidity
Idiopathic Toe Walking (ITW): Often occurs in otherwise healthy children. May be linked to mild sensory processing issues. Increased prevalence in children with family history of toe walking.
Gradual onset in most cases (especially ITW or neurodevelopmental conditions).
Progressive or worsening pattern may suggest neuromuscular disease.
Acute presentation is rare but may occur (e.g., sudden onset after viral illness).
Severity may range from mild and flexible to fixed contractures affecting function.
Differential Diagnoses
Idiopathic Toe Walking (ITW)
Cerebral Palsy (CP)
Tethered Cord Syndrome
Diastematomyelia or Spina Bifida Occulta
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
Observation Phase: For toddlers with idiopathic toe walking (ITW), simple monitoring is advised as many outgrow it by age 3.
Nonoperative Management: First-line treatment includes stretching exercises, serial casting, ankle-foot orthoses (AFOs), and in some cases, botulinum toxin injections or whole-body vibration. These aim to improve ankle dorsiflexion and normalize gait.
Surgical Intervention: Reserved for persistent toe walking with fixed contractures or functional impairment. Procedures like Achilles tendon or gastrocnemius lengthening are performed based on muscle tightness and clinical tests.
Postoperative Care: Includes casting, pain management, and gradual weightbearing. Orthotics may be used to prevent recurrence.
Long-Term Monitoring: Follow-up over 1–2 years ensures recovery of strength and detects recurrence, especially in neuromuscular conditions.
Stretching is typically the first-line intervention, aiming to maintain or improve ankle range of motion (ROM), especially in children with ITW. Effective techniques involve using body weight for passive stretching, such as block-assisted heel drops or wall leans. However, outcomes are often limited without adjunct therapies.
Whole-body vibration therapy has shown short-term improvements in heel strike and ankle ROM, likely due to neuromodulation, though effects are not sustained.
Serial casting involves progressively stretching the Achilles tendon by weekly or biweekly cast changes, gradually increasing dorsiflexion. Though useful, especially for spastic equinus, recurrence is common without follow-up support such as orthotics.
Ankle-foot orthoses (AFOs) are custom devices that prevent plantarflexion while allowing dorsiflexion. Articulated AFOs support ambulation and help maintain ROM post-casting. They are particularly effective in children with spasticity and can delay or reduce the need for surgery.
Although botulinum toxin injections have been explored for ITW, studies show limited and short-lived benefits compared to their established role in spasticity from cerebral palsy.
Role of Botulinum Toxin Type A
OnabotulinumtoxinA: It is used for reducing gastrocnemius-soleus muscle spasticity in children with spastic toe walking, including in CP. It blocks acetylcholine release at the neuromuscular junction, temporarily weakening the spastic muscle. Route of Administration is through Intramuscular injection into the gastrocnemius medialis and lateralis. Individualized based on weight, muscle mass, and severity of spasticity; typically administered every 3 to 6 months.
The effect duration is approximately 3 to 6 months. The adjunct therapy is more effective when combined with physical therapy, stretching, and orthotic use (e.g., ankle-foot orthoses). Limited for idiopathic toe walking (ITW); more beneficial in spastic etiologies like CP.
When conservative measures fail after about 12 months, surgical intervention may be indicated—especially if ankle equinus significantly affects gait. The most common procedure is Achilles tendon lengthening, performed either openly or via a percutaneous technique. Open surgery involves a medial or transverse incision, followed by Z-lengthening of the tendon and postoperative immobilization in a cast for 6 weeks. Percutaneous lengthening uses small stab incisions to selectively release tendon fibers, correcting equinus with less invasive exposure.
In cases with spasticity or neurologic involvement, selective gastrocnemius or Achilles lengthening is used, guided by tests like the Silfverskiöld test to avoid over-weakening. For example, the Strayer or Vulpius procedures may be chosen depending on the muscle-tendon segment involved. Careful evaluation is essential in conditions like Duchenne muscular dystrophy, where heel-cord lengthening may worsen mobility and is generally avoided.
use-of-phases-in-managing-toe-walking
The management of toe walking follows a phased approach. In the observation phase, toddlers with idiopathic toe walking (ITW) and no fixed contractures are monitored every 6–12 months, as many improve spontaneously; treatment is considered if symptoms persist beyond age 3. The nonoperative phase is the first line of active treatment and includes stretching exercises, serial casting, orthotic devices (AFOs), botulinum toxin injections for spasticity, and whole-body vibration, especially useful in spastic or paralytic cases. If nonoperative efforts fail after about a year or if gait is significantly impaired, the surgical phase may involve Achilles or selective muscle-tendon lengthening, tailored to the underlying condition. In the postoperative phase, casting for 4–6 weeks, pain management, and orthotic use aid recovery and reduce recurrence. Finally, the long-term monitoring phase involves follow-up for 1–2 years, especially in neuromuscular cases, with continued use of orthotics and stretching to prevent contracture recurrence.
Toe walking is a gait abnormality where the heels do not contact the ground during walking, and the forefoot bears most of the body weight throughout the gait cycle. It is defined by the absence of heel strike in the initial stance phase and incomplete foot contact during the rest of the gait.
Toe walking can result from various causes, ranging from habitual behavior to serious neuromuscular conditions. The most common form is idiopathic toe walking (ITW), a diagnosis made when no underlying medical cause is found. In contrast, non-idiopathic toe walking (non-ITW) is linked to identifiable conditions, often neurological or muscular in origin, and requires careful diagnosis to guide treatment and assess the likelihood of recurrence.
While toe walking is typical in toddlers learning to walk, most children adopt a heel-to-toe gait by around 22 months. If the pattern continues beyond age 2, further assessment is recommended.
Treatment is tailored to the individual, considering age, severity, and cause. Options range from watchful waiting to surgical interventions. One common surgical treatment is Achilles tendon tenotomy, a long-established orthopedic procedure.
The true prevalence of idiopathic toe walking (ITW) is unclear due to underreporting, but studies suggest it affects 2% to 24% of children, depending on the population studied. Higher rates are observed in children with developmental or neuropsychiatric conditions, such as autism, ADHD, and language disorders. For instance, up to 20% of children with autism exhibit toe walking.
A 2016 study by Baber et al found that children with ITW were more likely to be born prematurely, have lower birth weights, and require neonatal intensive care. Though assisted births were more common in medical cases, no strong link was found with ITW alone. Delivery complications were more frequent among ITW cases, suggesting a possible connection to motor development issues.
Non-idiopathic toe walking is commonly associated with cerebral palsy (CP) and Duchenne muscular dystrophy (DMD). In CP, toe walking varies by severity and affects fewer than half of patients. In DMD, toe walking develops over time due to muscle degeneration and tendon contractures.
The underlying mechanisms of idiopathic toe walking (ITW) are not fully understood, but it is thought to involve subtle sensory processing issues, possibly linked to vestibular dysfunction or heightened tactile sensitivity. However, scientific evidence supporting these theories is limited.
There is some indication of a genetic basis for ITW, as many case series report a positive family history. Originally, ITW was associated with congenital shortening of the Achilles tendon, leading to ankle equinus and toe walking. However, later studies have shown that not all children with ITW have structural abnormalities; some are capable of walking flat-footed and may exhibit a habitual or voluntary toe-walking pattern.
Non-idiopathic toe walking can result from neurologic or muscular causes, most notably cerebral palsy (CP) and Duchenne muscular dystrophy (DMD). In CP, toe walking usually arises from lower-limb spasticity. This can cause ankle equinus due to slow growth of spastic muscles and, additionally, result from compensatory toe walking when hip and knee flexion prevent stable upright posture.
In DMD, progressive muscle degeneration weakens the foot dorsiflexors more than the plantarflexors, and toe walking may develop as a compensatory strategy. As the quadriceps weaken, patients lose knee extension strength, leading to a flexed knee posture. Walking on the forefoot creates a mechanical advantage that helps stabilize the knee during gait.
Toe walking can be classified into two main types: idiopathic (ITW) and non-idiopathic. Non-ITW is linked to identifiable medical conditions, including neurological disorders (such as spina bifida, cerebral palsy, tethered cord, and diastematomyelia), muscle-related conditions (like congenital muscular dystrophy), and structural issues such as differences in limb length. Rarely, toe walking may occur due to temporary conditions, such as viral myositis, as reported in an otherwise healthy child.
Idiopathic toe walking is the most frequently observed form, characterized by the absence of an underlying medical cause. Initially described in 1967 as “habitual toe walking” or due to a “congenital short Achilles tendon,” ITW is diagnosed only after other causes are ruled out. It typically presents as bilateral toe walking in children over the age of two, with or without tightness in the Achilles tendon.
Toe walking can be classified into two main types: idiopathic (ITW) and non-idiopathic. Non-ITW is linked to identifiable medical conditions, including neurological disorders (such as spina bifida, cerebral palsy, tethered cord, and diastematomyelia), muscle-related conditions (like congenital muscular dystrophy), and structural issues such as differences in limb length. Rarely, toe walking may occur due to temporary conditions, such as viral myositis, as reported in an otherwise healthy child.
Idiopathic toe walking is the most frequently observed form, characterized by the absence of an underlying medical cause. Initially described in 1967 as “habitual toe walking” or due to a “congenital short Achilles tendon,” ITW is diagnosed only after other causes are ruled out. It typically presents as bilateral toe walking in children over the age of two, with or without tightness in the Achilles tendon.
Age Group:
Commonly observed in toddlers learning to walk (normal up to age 2 years).
Persistent toe walking beyond age 2 warrants further evaluation.
Most children with idiopathic toe walking (ITW) present between 2–5 years.
Non-idiopathic toe walking may present earlier or later depending on the underlying disorder.
The physical examination of a child with toe walking aims to exclude known neurological, muscular, or orthopedic causes before diagnosing idiopathic toe walking (ITW). It begins with observing the child’s overall appearance and gait, followed by inspection of the spine and lower limbs for abnormalities such as leg-length discrepancy, muscle asymmetry, or foot deformities. Neurologic assessment includes evaluating muscle strength through functional tasks like rising from the floor or climbing onto an exam table, along with reflexes, tone, and response to stimuli. Joint range of motion, especially at the ankle, should be tested using the Silfverskiöld test, with dorsiflexion assessed in a neutral heel position. In ITW, findings are typically normal except for bilateral toe walking and possible heel-cord tightness. Asymmetry in toe walking suggests an alternative diagnosis.
Idiopathic Toe Walking (ITW): Often occurs in otherwise healthy children. May be linked to mild sensory processing issues. Increased prevalence in children with family history of toe walking.
Gradual onset in most cases (especially ITW or neurodevelopmental conditions).
Progressive or worsening pattern may suggest neuromuscular disease.
Acute presentation is rare but may occur (e.g., sudden onset after viral illness).
Severity may range from mild and flexible to fixed contractures affecting function.
Idiopathic Toe Walking (ITW)
Cerebral Palsy (CP)
Tethered Cord Syndrome
Diastematomyelia or Spina Bifida Occulta
Observation Phase: For toddlers with idiopathic toe walking (ITW), simple monitoring is advised as many outgrow it by age 3.
Nonoperative Management: First-line treatment includes stretching exercises, serial casting, ankle-foot orthoses (AFOs), and in some cases, botulinum toxin injections or whole-body vibration. These aim to improve ankle dorsiflexion and normalize gait.
Surgical Intervention: Reserved for persistent toe walking with fixed contractures or functional impairment. Procedures like Achilles tendon or gastrocnemius lengthening are performed based on muscle tightness and clinical tests.
Postoperative Care: Includes casting, pain management, and gradual weightbearing. Orthotics may be used to prevent recurrence.
Long-Term Monitoring: Follow-up over 1–2 years ensures recovery of strength and detects recurrence, especially in neuromuscular conditions.
Orthopaedic Surgery
Stretching is typically the first-line intervention, aiming to maintain or improve ankle range of motion (ROM), especially in children with ITW. Effective techniques involve using body weight for passive stretching, such as block-assisted heel drops or wall leans. However, outcomes are often limited without adjunct therapies.
Whole-body vibration therapy has shown short-term improvements in heel strike and ankle ROM, likely due to neuromodulation, though effects are not sustained.
Serial casting involves progressively stretching the Achilles tendon by weekly or biweekly cast changes, gradually increasing dorsiflexion. Though useful, especially for spastic equinus, recurrence is common without follow-up support such as orthotics.
Ankle-foot orthoses (AFOs) are custom devices that prevent plantarflexion while allowing dorsiflexion. Articulated AFOs support ambulation and help maintain ROM post-casting. They are particularly effective in children with spasticity and can delay or reduce the need for surgery.
Although botulinum toxin injections have been explored for ITW, studies show limited and short-lived benefits compared to their established role in spasticity from cerebral palsy.
Orthopaedic Surgery
OnabotulinumtoxinA: It is used for reducing gastrocnemius-soleus muscle spasticity in children with spastic toe walking, including in CP. It blocks acetylcholine release at the neuromuscular junction, temporarily weakening the spastic muscle. Route of Administration is through Intramuscular injection into the gastrocnemius medialis and lateralis. Individualized based on weight, muscle mass, and severity of spasticity; typically administered every 3 to 6 months.
The effect duration is approximately 3 to 6 months. The adjunct therapy is more effective when combined with physical therapy, stretching, and orthotic use (e.g., ankle-foot orthoses). Limited for idiopathic toe walking (ITW); more beneficial in spastic etiologies like CP.
Orthopaedic Surgery
When conservative measures fail after about 12 months, surgical intervention may be indicated—especially if ankle equinus significantly affects gait. The most common procedure is Achilles tendon lengthening, performed either openly or via a percutaneous technique. Open surgery involves a medial or transverse incision, followed by Z-lengthening of the tendon and postoperative immobilization in a cast for 6 weeks. Percutaneous lengthening uses small stab incisions to selectively release tendon fibers, correcting equinus with less invasive exposure.
In cases with spasticity or neurologic involvement, selective gastrocnemius or Achilles lengthening is used, guided by tests like the Silfverskiöld test to avoid over-weakening. For example, the Strayer or Vulpius procedures may be chosen depending on the muscle-tendon segment involved. Careful evaluation is essential in conditions like Duchenne muscular dystrophy, where heel-cord lengthening may worsen mobility and is generally avoided.
Orthopaedic Surgery
The management of toe walking follows a phased approach. In the observation phase, toddlers with idiopathic toe walking (ITW) and no fixed contractures are monitored every 6–12 months, as many improve spontaneously; treatment is considered if symptoms persist beyond age 3. The nonoperative phase is the first line of active treatment and includes stretching exercises, serial casting, orthotic devices (AFOs), botulinum toxin injections for spasticity, and whole-body vibration, especially useful in spastic or paralytic cases. If nonoperative efforts fail after about a year or if gait is significantly impaired, the surgical phase may involve Achilles or selective muscle-tendon lengthening, tailored to the underlying condition. In the postoperative phase, casting for 4–6 weeks, pain management, and orthotic use aid recovery and reduce recurrence. Finally, the long-term monitoring phase involves follow-up for 1–2 years, especially in neuromuscular cases, with continued use of orthotics and stretching to prevent contracture recurrence.
Toe walking is a gait abnormality where the heels do not contact the ground during walking, and the forefoot bears most of the body weight throughout the gait cycle. It is defined by the absence of heel strike in the initial stance phase and incomplete foot contact during the rest of the gait.
Toe walking can result from various causes, ranging from habitual behavior to serious neuromuscular conditions. The most common form is idiopathic toe walking (ITW), a diagnosis made when no underlying medical cause is found. In contrast, non-idiopathic toe walking (non-ITW) is linked to identifiable conditions, often neurological or muscular in origin, and requires careful diagnosis to guide treatment and assess the likelihood of recurrence.
While toe walking is typical in toddlers learning to walk, most children adopt a heel-to-toe gait by around 22 months. If the pattern continues beyond age 2, further assessment is recommended.
Treatment is tailored to the individual, considering age, severity, and cause. Options range from watchful waiting to surgical interventions. One common surgical treatment is Achilles tendon tenotomy, a long-established orthopedic procedure.
The true prevalence of idiopathic toe walking (ITW) is unclear due to underreporting, but studies suggest it affects 2% to 24% of children, depending on the population studied. Higher rates are observed in children with developmental or neuropsychiatric conditions, such as autism, ADHD, and language disorders. For instance, up to 20% of children with autism exhibit toe walking.
A 2016 study by Baber et al found that children with ITW were more likely to be born prematurely, have lower birth weights, and require neonatal intensive care. Though assisted births were more common in medical cases, no strong link was found with ITW alone. Delivery complications were more frequent among ITW cases, suggesting a possible connection to motor development issues.
Non-idiopathic toe walking is commonly associated with cerebral palsy (CP) and Duchenne muscular dystrophy (DMD). In CP, toe walking varies by severity and affects fewer than half of patients. In DMD, toe walking develops over time due to muscle degeneration and tendon contractures.
The underlying mechanisms of idiopathic toe walking (ITW) are not fully understood, but it is thought to involve subtle sensory processing issues, possibly linked to vestibular dysfunction or heightened tactile sensitivity. However, scientific evidence supporting these theories is limited.
There is some indication of a genetic basis for ITW, as many case series report a positive family history. Originally, ITW was associated with congenital shortening of the Achilles tendon, leading to ankle equinus and toe walking. However, later studies have shown that not all children with ITW have structural abnormalities; some are capable of walking flat-footed and may exhibit a habitual or voluntary toe-walking pattern.
Non-idiopathic toe walking can result from neurologic or muscular causes, most notably cerebral palsy (CP) and Duchenne muscular dystrophy (DMD). In CP, toe walking usually arises from lower-limb spasticity. This can cause ankle equinus due to slow growth of spastic muscles and, additionally, result from compensatory toe walking when hip and knee flexion prevent stable upright posture.
In DMD, progressive muscle degeneration weakens the foot dorsiflexors more than the plantarflexors, and toe walking may develop as a compensatory strategy. As the quadriceps weaken, patients lose knee extension strength, leading to a flexed knee posture. Walking on the forefoot creates a mechanical advantage that helps stabilize the knee during gait.
Toe walking can be classified into two main types: idiopathic (ITW) and non-idiopathic. Non-ITW is linked to identifiable medical conditions, including neurological disorders (such as spina bifida, cerebral palsy, tethered cord, and diastematomyelia), muscle-related conditions (like congenital muscular dystrophy), and structural issues such as differences in limb length. Rarely, toe walking may occur due to temporary conditions, such as viral myositis, as reported in an otherwise healthy child.
Idiopathic toe walking is the most frequently observed form, characterized by the absence of an underlying medical cause. Initially described in 1967 as “habitual toe walking” or due to a “congenital short Achilles tendon,” ITW is diagnosed only after other causes are ruled out. It typically presents as bilateral toe walking in children over the age of two, with or without tightness in the Achilles tendon.
Toe walking can be classified into two main types: idiopathic (ITW) and non-idiopathic. Non-ITW is linked to identifiable medical conditions, including neurological disorders (such as spina bifida, cerebral palsy, tethered cord, and diastematomyelia), muscle-related conditions (like congenital muscular dystrophy), and structural issues such as differences in limb length. Rarely, toe walking may occur due to temporary conditions, such as viral myositis, as reported in an otherwise healthy child.
Idiopathic toe walking is the most frequently observed form, characterized by the absence of an underlying medical cause. Initially described in 1967 as “habitual toe walking” or due to a “congenital short Achilles tendon,” ITW is diagnosed only after other causes are ruled out. It typically presents as bilateral toe walking in children over the age of two, with or without tightness in the Achilles tendon.
Age Group:
Commonly observed in toddlers learning to walk (normal up to age 2 years).
Persistent toe walking beyond age 2 warrants further evaluation.
Most children with idiopathic toe walking (ITW) present between 2–5 years.
Non-idiopathic toe walking may present earlier or later depending on the underlying disorder.
The physical examination of a child with toe walking aims to exclude known neurological, muscular, or orthopedic causes before diagnosing idiopathic toe walking (ITW). It begins with observing the child’s overall appearance and gait, followed by inspection of the spine and lower limbs for abnormalities such as leg-length discrepancy, muscle asymmetry, or foot deformities. Neurologic assessment includes evaluating muscle strength through functional tasks like rising from the floor or climbing onto an exam table, along with reflexes, tone, and response to stimuli. Joint range of motion, especially at the ankle, should be tested using the Silfverskiöld test, with dorsiflexion assessed in a neutral heel position. In ITW, findings are typically normal except for bilateral toe walking and possible heel-cord tightness. Asymmetry in toe walking suggests an alternative diagnosis.
Idiopathic Toe Walking (ITW): Often occurs in otherwise healthy children. May be linked to mild sensory processing issues. Increased prevalence in children with family history of toe walking.
Gradual onset in most cases (especially ITW or neurodevelopmental conditions).
Progressive or worsening pattern may suggest neuromuscular disease.
Acute presentation is rare but may occur (e.g., sudden onset after viral illness).
Severity may range from mild and flexible to fixed contractures affecting function.
Idiopathic Toe Walking (ITW)
Cerebral Palsy (CP)
Tethered Cord Syndrome
Diastematomyelia or Spina Bifida Occulta
Observation Phase: For toddlers with idiopathic toe walking (ITW), simple monitoring is advised as many outgrow it by age 3.
Nonoperative Management: First-line treatment includes stretching exercises, serial casting, ankle-foot orthoses (AFOs), and in some cases, botulinum toxin injections or whole-body vibration. These aim to improve ankle dorsiflexion and normalize gait.
Surgical Intervention: Reserved for persistent toe walking with fixed contractures or functional impairment. Procedures like Achilles tendon or gastrocnemius lengthening are performed based on muscle tightness and clinical tests.
Postoperative Care: Includes casting, pain management, and gradual weightbearing. Orthotics may be used to prevent recurrence.
Long-Term Monitoring: Follow-up over 1–2 years ensures recovery of strength and detects recurrence, especially in neuromuscular conditions.
Orthopaedic Surgery
Stretching is typically the first-line intervention, aiming to maintain or improve ankle range of motion (ROM), especially in children with ITW. Effective techniques involve using body weight for passive stretching, such as block-assisted heel drops or wall leans. However, outcomes are often limited without adjunct therapies.
Whole-body vibration therapy has shown short-term improvements in heel strike and ankle ROM, likely due to neuromodulation, though effects are not sustained.
Serial casting involves progressively stretching the Achilles tendon by weekly or biweekly cast changes, gradually increasing dorsiflexion. Though useful, especially for spastic equinus, recurrence is common without follow-up support such as orthotics.
Ankle-foot orthoses (AFOs) are custom devices that prevent plantarflexion while allowing dorsiflexion. Articulated AFOs support ambulation and help maintain ROM post-casting. They are particularly effective in children with spasticity and can delay or reduce the need for surgery.
Although botulinum toxin injections have been explored for ITW, studies show limited and short-lived benefits compared to their established role in spasticity from cerebral palsy.
Orthopaedic Surgery
OnabotulinumtoxinA: It is used for reducing gastrocnemius-soleus muscle spasticity in children with spastic toe walking, including in CP. It blocks acetylcholine release at the neuromuscular junction, temporarily weakening the spastic muscle. Route of Administration is through Intramuscular injection into the gastrocnemius medialis and lateralis. Individualized based on weight, muscle mass, and severity of spasticity; typically administered every 3 to 6 months.
The effect duration is approximately 3 to 6 months. The adjunct therapy is more effective when combined with physical therapy, stretching, and orthotic use (e.g., ankle-foot orthoses). Limited for idiopathic toe walking (ITW); more beneficial in spastic etiologies like CP.
Orthopaedic Surgery
When conservative measures fail after about 12 months, surgical intervention may be indicated—especially if ankle equinus significantly affects gait. The most common procedure is Achilles tendon lengthening, performed either openly or via a percutaneous technique. Open surgery involves a medial or transverse incision, followed by Z-lengthening of the tendon and postoperative immobilization in a cast for 6 weeks. Percutaneous lengthening uses small stab incisions to selectively release tendon fibers, correcting equinus with less invasive exposure.
In cases with spasticity or neurologic involvement, selective gastrocnemius or Achilles lengthening is used, guided by tests like the Silfverskiöld test to avoid over-weakening. For example, the Strayer or Vulpius procedures may be chosen depending on the muscle-tendon segment involved. Careful evaluation is essential in conditions like Duchenne muscular dystrophy, where heel-cord lengthening may worsen mobility and is generally avoided.
Orthopaedic Surgery
The management of toe walking follows a phased approach. In the observation phase, toddlers with idiopathic toe walking (ITW) and no fixed contractures are monitored every 6–12 months, as many improve spontaneously; treatment is considered if symptoms persist beyond age 3. The nonoperative phase is the first line of active treatment and includes stretching exercises, serial casting, orthotic devices (AFOs), botulinum toxin injections for spasticity, and whole-body vibration, especially useful in spastic or paralytic cases. If nonoperative efforts fail after about a year or if gait is significantly impaired, the surgical phase may involve Achilles or selective muscle-tendon lengthening, tailored to the underlying condition. In the postoperative phase, casting for 4–6 weeks, pain management, and orthotic use aid recovery and reduce recurrence. Finally, the long-term monitoring phase involves follow-up for 1–2 years, especially in neuromuscular cases, with continued use of orthotics and stretching to prevent contracture recurrence.
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