Idiopathic Toe Walking

Original Editor - Lauren Heydenrych Top Contributors - Lauren Heydenrych, Jess Bell, Robin Tacchetti, Tarina van der Stockt and Kim Jackson

Introduction

Toe walking is often described as "the lack of heel strike at the initial contact phase of the gait cycle." In children aged two or under, toe walking is generally considered a normal gait variation; children usually demonstrate ankle dorsiflexion at heel strike by the age of five years.

Toe walking can be associated with specific conditions, trauma or neurogenic influences. Conditions that can cause toe walking include cerebral palsy, muscular dystrophy, autism spectrum disorders, global developmental delays, tumours or lower limb injuries.

Toe walking that is caused by a specific condition is distinct from idiopathic toe walking (ITW). ITW is an umbrella term for toe walking in otherwise healthy, ambulant children. ITW is a diagnosis of exclusion, where no determinable pathology exists. ITW is also known as toe walking, habitual toe walking, and congenital short tendo calcaneus.

In ITW, there is an absence of heel strike during initial contact, and the foot does not make full contact during the stance phase of gait. Weight is kept primarily on the forefoot, often on the metatarsal heads.

It can be defined as: “an equinus gait, initially without fixed contractures, with passive dorsiflexion range of motion (ROM) of the plantar flexor musculature to dorsiflex to at least neutral (0°) with the subtalar joint inverted and with the knee extended."

ITW may initially present during pre-walking skill acquisition, at the start of independent walking, or within six months of the initiation of independent walking. Some individuals with ITW will toe walk intermittently while others exclusively toe walk. Children with ITW are generally less stable during gait and have a heightened risk of slipping or falling. They may also experience leg or foot pain and reduced ankle dorsiflexion passive range of motion, which can predispose these children to ankle injuries.

For a toe-toe gait to be considered ITW:

• a child must have started toe walking as soon as they were independently ambulating or soon after
• toe walking will be bilateral (not unilateral)
• individuals with ITW are aged from around 2 to 21 years
  • toe-walking tends to resolve spontaneously in most children
  • one cohort study found that by the age of 10 years, 79% of children who toe-walked had spontaneously developed a typical gait

Epidemiology and Aetiology

Reports of the incidence of ITW vary considerably, from 2-5% to 7-24%. ITW affects boys more than girls.

Equinus foot/ Forefoot weight bearing

The aetiology of ITW is unknown:

• ITW is associated with ankle equinus. Individuals with ITW often present with tightness or reduced range in their ankle plantar flexors, which develops over time with persistent toe walking. Ankle dorsiflexion range of motion also decreases with time. Reduced range of motion was initially thought to be a cause of ITW, but it is now believed to occur as a result of ITW.
• There may be a genetic component to ITW in some individuals - a strong family history is present in some children with ITW.
• There is a positive correlation between ITW and individuals who have language delays and learning disabilities.
• There is an unconfirmed relationship between ITW and some sensory processing disorders (e.g. in children with tactile, proprioceptive, vestibular and visual processing issues).
  • Please note that the diagnosis of ITW does not apply to individuals who have autism spectrum disorder or developmental delay.
• It has also been suggested that ITW occurs due to hyperactive reflexes - i.e. a delay in maturation of the corticospinal tract results in a lack of inhibition of the stretch reflexes and subsequent increased deep tendon reflexes. A literature review by Lorentzen et al. found that corticospinal pathways are active and important at the level of the presynapse of motor neurons of the ankle plantar flexors.

Diagnosis

ITW is a diagnosis of exclusion. The following conditions must be ruled out in the differential diagnosis:

• Neuromotor disease
• Neuromuscular disease
• Cerebral palsy
• Spina bifida
• Tethered cord syndrome
• Spinal dysraphism
• Spinal cord tumour

The Toe-walking tool is a series of questions that has been proposed as a means to help distinguish ITW from other conditions.

Biomechanical Changes

As children with ITW get older, certain biomechanical changes can occur as a result of persistent toe walking:

• Children with ITW can present with shortened Achilles tendons and contractures of the foot and ankle joints. This is more common in older children presenting with ITW.
• Children with ITW develop foot pronation and, potentially, significant foot abduction (out-toeing). They may also have excessive tibial torsion.
• Muscle biopsies indicate that children with ITW have a higher percentage of type I muscle fibres (i.e. tonic, slow contracting, fatigue resistant fibres) in the gastrocnemius muscle than type II muscle fibres (fast twitch fibres). This change reflects the different forces and demands that are placed on gastrocnemius with persistent toe walking.

Management

Because there is no clear aetiology for ITW, Davies et al. note that it is difficult to determine if treatments should focus on toe walking, motor or sensory issues or passive ankle range of motion. However, the initial management for ITW is conservative. Surgical interventions may be considered when conservative measures have been exhausted.

Conservative management

Conservative interventions for ITW typically include the following:

• Stretching
• Orthotics or night splints
• Serial casting
• Footwear
• Auditory feedback
• Botulinum toxin type A (BTX)
• Gait retraining

Physiotherapy management

As with all therapeutic interventions, the initial consultation begins with a thorough assessment, followed by treatment and reassessment.

Assessment

The components of the physiotherapy examination for ITW are discussed fully in the Cincinnati Children’s Hospital Medical Centre’s Guideline in the Management of Idiopathic Toe Walking, including the following:

• Subjective examination
• Objective examination, including screening measures
• Physical examination
• Gait examination
• Gross motor skills

For more information, please see: Evidence-based Clinical Care Guideline for Management of Idiopathic Toe Walking.

Subjective examination

• Birth history
• Medical history
• Developmental history, including:
  • gross motor skills development
  • balance concerns
  • onset of toe walking
• Family history of toe walking, and/or any conditions associated with toe walking
• Current and past therapeutic interventions, such as occupational therapy, physiotherapy, speech therapy etc

Objective screening

• Pain assessment using an appropriate pain scale
• Speech and language screening
  • Use the communication subsection of the Ages and Stages Questionnaire (suitable for children aged four months to 60 months) if indicated
• Complete the Short Sensory Profile (suitable for children aged three years to 10 years 11 months) by the first treatment visit as a sensory processing screen

Physical examination

• The neurological assessment should include:
  • assessment of the tone of ankle plantar flexors and knee flexors using the Modified Ashworth Scale
  • assessment for clonus
• The musculoskeletal examination should include:
  • range of motion (ROM) testing:
    • passive ROM of ankle dorsiflexion in subtalar neutral (STN), with knee flexed and extended
    • active ROM of ankle dorsiflexion with knee extended
  • muscle length testing, including:
    • Thomas test (hip flexors)
    • hamstring length test
      • hamstring length varies based on age - the hamstring index summarises these changes in length
  • lower extremity alignment, including:
    • thigh foot angle
    • hindfoot / forefoot alignment in subtalar neutral (in non-weight bearing)
  • standing posture
  • strength of the following muscles using manual muscle testing and / or functional assessments:
    • anterior tibialis
    • gastrocnemius
  • assessment of trunk and core
• Gait examination:
  • Observational Gait Scale
  • parent report of percentage of time toe walking
• Gross motor skills assessment, including:
  • squatting to / from a standing position, position of foot while squatting
  • transitioning from floor to stand
  • stairs
  • balance, including:
    • static and dynamic balance
    • single limb stance
    • balance beam
    • jumping and hopping
  • coordination
  • determining the need for standardised testing

Further details on progressive reassessment during follow-up consultations can be found in the Cincinnati Children’s Hospital Medical Centre’s Guideline.

Physiotherapy intervention

A physiotherapist's role in the management of ITW is multidimensional and includes:

• hands-on therapy
  • active and passive range exercises, with an emphasis on ankle range of motion. When stretching gastrocnemius and soleus, it is important to make sure that exercises are performed in subtalar neutral
  • strength training, particularly of tibialis anterior and the trunk muscles
  • gait training, including treadmill training
  • kinesiotaping along tibialis anterior
  • home exercise programme

• in addition to the above, the physiotherapist may also be involved in footwear, casting and orthotic interventions

Surgical management

Surgical interventions described in the literature include:

• vulpius procedure (gastrocnemius recession surgery)
• tendon Achilles lengthening
• open Achilles tendon lengthening via a Z-lengthening or slide technique
• Baker’s gastrocnemius-soleus lengthening

Side effects to surgical management noted in Caserta et al. and Van Kuijk et al. included excessive ankle dorsiflexion after Achilles tendon lengthening.

Resources

• Liesa Ritchie-Persaud's Top Tips and Tools for Treating Toe-Walking
• Dr Cylie Williams: A Podiatrist's Perspective on paediatric feet and gait concerns