A benign phase of youth, or a harmful condition requiring treatment?
Vol. 24 • Issue 22 • Page 16
While it’s not abnormal for children to walk on their toes for a short period when they first begin to ambulate, prolonged toe-walking is not a component of normal development. The notion that children will simply outgrow toe-walking is not necessarily true. Physical therapy is an integral part of treatment for ITW, encompassing treatments consisting of therapeutic activities such as stretching, strengthening and sensory input, as well as recommendations for bracing.
In my work as a clinician in both outpatient clinics and school systems, I’ve observed many children with a toe-toe gait pattern who do not have other conditions such as cerebral palsy causing weakness or abnormal muscle firing that may result in toe-walking. They range in age from toddlers to those attending high school.
Toe-walking may occur in concert with speech delays, autism, low muscle tone or general developmental delay. However, the exact etiology of toe-walking, whether it’s due to a sensory integration deficit, or weakness that forces the child to adopt the position for walking stability, is essentially guesswork.
There’s great variability in the age in which children present with toe-walking. Likewise, some children walk up on the tips of their toes, while others walk on their forefeet. Some children do this nearly all of the time, others intermittently. However, one thing remains definitive – none of the children contact the ground with their heel during the gait cycle.
Defining and Diagnosing ITW
According to Clark et al., while toe-walking, “children walk with a toe-toe gait pattern in the absence of any known cause.”1 The child’s neurological exam is normal with respect to muscle tone, reflexes, sensation and strength, and the child may or may not have a passive limitation in ankle dorsiflexion.
Regardless of the findings, it’s theorized that ITW may be one element of a more global neuro-developmental condition, since many of these children present with other diagnoses concomitantly. Many young children are recognized as having a toe-walking pattern when they first start to walk, which is not considered an anomaly.
However, if this pattern persists beyond 2-3 years of age, it should be labeled as ITW in the absence of any other pathology.1 Le Cras et al. reported a higher incidence of ITW in males than females, and that a positive family history of ITW often exists.2 A “consistent” heel strike by about 18 months of age or up to six months after the child begins walking independently is considered normal.
Shulman et al. also found that children with ITW present with other developmental problems, principally language delays; and to a lesser extent, fine- and gross-motor deficits and visuo-motor impairments.3 Engstrom et al. estimated the prevalence of toe-walking in the general population. Of the children in the study cohort, 2.79% were previous toe-walkers, and 2.09% continued to toe-walk at 5.5 years of age. Children with a diagnosis of developmental delay or neuropsychiatric disorder had a prevalence of toe-walking of 41.2% (both inactive and active toe-walkers).4
Diagnosing ITW is made by exclusion, and the cause is unknown. It may occur in as many as 5 out of 500 births. In neurological conditions such as CP, treatments such a physical therapy, Botox injections and surgery are more accepted; however, for ITW in which causation has not been ascertained, treatment options are not as clear cut.Zimbler posited that physicians must differentiate ITW from other conditions that may cause toe-walking, such as CP, myopathies and spinal conditions, by performing a thorough history, blood tests and MRIs if warranted.5 Children with developmental disorders such as autism, pervasive developmental disorder (PDD), cognitive deficits, and sensory integration disorders may also present with toe-walking.
Williams et al. studied sensory processing disorder (SPD) and its relationship to toe-walking. While there is interest in the connection between SPD and ITW, and many texts have been written on the subject, presently there is nothing but anecdotal evidence regarding causation.6
Eiff et al. found that there is “no convincing evidence that treatment is necessary” for ITW.7 The authors stated there are no randomized clinical studies that are of adequate size to demonstrate treatment for ITW helps a child later in life, and propose that no interventions are necessary.
Hirsh and Wagner described no lasting improvements in toe-walking with conservative treatment in 16 patients followed 7-21 years after diagnosis. They posited that surgical treatment should be performed, but only on a select few who have fixed contractures.8 Clark et al. concluded that Botox in conjunction with serial casting and physical therapy is a standard treatment for ITW; however, effects can be short-lived, and if the treatment is at all effective, an AFO is still needed to prevent a return to toe-walking.1
Lundequam and Willis completed a study of dynamic splinting combined with physical therapy and Botox injections in a 5-year-old child with right hemiparesis who already used an articulating brace. After four months the child gained 14 degrees of active dorsiflexion and 9 degrees of passive dorsiflexion, and was able to walk barefoot with the foot flat.9
Engstrom et al. found that one injection of Botox and a home exercise program improved joint kinematics at the ankle, and ameliorated toe-walking after a year follow-up in a majority of children.4 Clark et al. looked at motor-control interventions in lieu of an orthopedic-based treatment protocol involving interventions such as stretching to increase ankle dorsiflexion range of motion. The authors did not find a significant improvement in measures of toe-walking, though they did find improvement in ankle dorsiflexion range of motion.1
Herrin et al. used bracing in isolation as an intervention to treat ITW. Findings supported using an articulating ankle-foot orthosis (AAFO) as statistically better than a foot orthosis (FO) in regard to the percent of time spent toe-walking per parental report.10 Schwentker and Calhoun preferred the use of molded ankle-foot orthoses (MAFOs) with articulation to stretch the Achilles tendon.11 This should be worn at least six months during waking hours in addition to performing stretching in a weight-bearing position.
Lasting Effects of Toe-Walking
Fox et al. commented that there have been no quality long-term prospective studies comparing treatments for ITW, and it’s not known whether the condition continues into skeletal maturity.12 But Fox added that even with treatment, gait patterns of individuals with ITW is likely never entirely normal.
Engelbert et al. found that kids with ITW have a three-time increase in the chance of severe limitations in ankle dorsiflexion.13 There are also “compensatory” strategies that transpire in order for the child to walk when there’s limited range of motion in the ankle, such as hindfoot valgus and exotorsion of the lower extremity, particularly in older kids. However, this isn’t necessarily recognized as true ITW.
Even with surgical interventions, though gait kinematics such as stride length and ankle dorsiflexion range are much better, gait deviations persist in individuals with ITW. McMulkin et al. studied children who have undergone procedures such as tendo-Achilles lengthening (TAL) and Vulpius (gastrocnemius) lengthening. These children continue to demonstrate slight deviations in joint kinematics, including decreased peak dorsiflexion in stance, minimal increase in anterior pelvic tilt, and external foot progression similar to before surgery.14 However, this may be considered inconsequential in some children.
Are children with ITW ever fully “cured” even though they may stop toe-walking? Schwentker and Calhoun stated that if a child doesn’t toe-walk for a year, the child would be considered cured.11
To Treat or Not to Treat
While ITW seems to be better defined in children when it occurs beyond a certain age, controversy lingers with regard to the optimal way to manage this condition. There has been a modicum of research into what causes toe-walking in the absence of another cause such as CP, but as the name states, it’s still idiopathic and the etiology remains conjecture at this time.
The underlying neurological or orthopedic causes are being studied, but a consensus remains elusive. Is ITW harmful to children? Will they simply grow out of this, or does it persist into adulthood with lasting consequences that affect joint kinematics, cause joint deterioration, or result in lifelong gait abnormalities? It seems that the jury is still out.
However, the body of evidence on this condition is expanding. It appears that biomechanically, there are issues in at least some children that may last into adulthood. Toe-walking may not be quite as benign as once thought. Do interventions including physical therapy and bracing alter or cure ITW? Again, research is emerging, but proof is lacking.
- Clark, E., Sweeney, J., Yocum, A., & McCoy, S. (2010). Effects of motor control intervention for children with idiopathic toe walking: A 5-case series. Pediatric Physical Therapy, 22, 417-426.
- Le Cras S., Bouck J., Brausch S., & Taylor-Haas, A. (2011, February 15). Management of idiopathic toe walking in children and young adults ages 2 through 21 years. Retrieved from www.cincinnatichildrens.org/WorkArea/linkit.aspx?LinkIdentifier
- Shulman L., Sala, D., Chu M., McCaul, P., & Sandler, B. (1997). Developmental implications of idiopathic toe walking. The Journal of Pediatrics, 130, 541-546.
- Engström, P., Gutierrez-Farewik, EM., Bartonek, A., Tedroff,K., Orefelt,C.,& Haglund-Åkerlind, Y. (2010). Does botulin toxin A improve the walking pattern in children with idiopathic toe-walking? Journal of Children’s Orthopedics, 4, 301-308.
- Zimbler, S. (2007) Idiopathic toe walking: Current evaluation and management. The Orthopedic Journal of Harvard Medical School Online, 9, 98-100.
- Williams CM., Tinley, P., & Curtin, M. (2010). Idiopathic toe walking and sensory processing dysfunction. Journal of Foot and Ankle Research, 3. Retrieved from http://www.jfootankleres.com/content/3/1/16
- Eiff, M., Steiner, E., Judkins D., &Winkler-Prins, V. (2006). What is the appropriate evaluation and treatment of children who are “toe walkers” ? The Journal of Family Practice, 55,447- 450.
- Hirsch, G., & Wagner, B. (2004). The natural history of idiopathic toe-walking: A long-term follow-up of fourteen conservatively treated children Acta Paediatrica, 93, 196-199.
- Lundequam P., & Willis F. (2009). Dynamic splinting home therapy for toe walking: a case report. Cases Journal. Retrieved from http://www.casesjournal.com/content/2/1/188.
- Herrin, K., Barner, K. & Geil, M. (2012). Clinical outcomes after orthotic treatment of idiopathic toe walking: AFO vs. FO. American Academy of Orthotists and Prosthetists, 38th Academy Annual Meeting and Scientific Symposium. Retrieved from http://www.oandp.org/publications/jop/2012/2012-79.pdf
- Schwentker, E., & Calhoun, J. (2012) Toe Walking Treatment and Management. Retrieved from http://emedicine.medscape.com/article/1235248-treatment#a1127
- Fox A., Deakin, S., Pettigrew G., & Paton, R. (2006). Serial casting in the treatment of idiopathic toe walkers and review of the literature. Acta Orthopaedica Belgica, 72, 722-730.
- Engelbert, R., Gorter, J., Uiterwaal, C., van de Putte, E., & Helders P. (2011). Idiopathic toe-walking in children, adolescents and young adults: a matter of local or generalised stiffness? BMC Musculoskeletal Disorders,12. Retrieved from http://www.biomedcentral.com/1471-2474/12/61
- McMulkin, M., Baird, G., Caskey, P., & Ferguson, R. (2006). Comprehensive outcomes of surgically treated idiopathic toe walkers. Journal of Pediatrics Orthopedics, 26, 606-611.