Difficulty in Walking

Idiopathic Toe Walking

Riley Kendall, MD; Sharda Udassi, MD;
Mori Stern, MD; and Sanjeev Y. Tuli, MD

University of Florida College of Medicine, Gainesville

A 4-year-old girl presented to a primary care clinic with a chief concern of abnormal gait. Her parents noted that the girl has been walking on her toes for the past several years, and that her gait is not typical. She began walking at approximately 13 months of age and has always walked on the tips of her toes. Her parents did not think there was a problem with her gait until recently.

The girl did not complain of pain and did not walk with a limp. She was able to walk flatfooted and to heel walk when asked to do so. Her toe walking did not cause any limitations in activity. No family members have a similar gait, and there was no history of trauma or injury to her lower extremities or hips. She had met all developmental milestones for her age, and her birth history was noncontributory. She was in prekindergarten and was doing well.

toe walking

On physical examination, the girl had full range of motion of all extremities, with full dorsiflexion and plantar flexion of both ankles. The arches of her bilateral feet were normal. Hip and knee strength were 5/5, with full flexion and extension. There was no joint deformity, swelling, or warmth in her lower extremities. Gowers sign was negative. There was no ankle spasticity or tightened Achilles tendon.

The girl received a diagnosis of idiopathic toe walking.

Etiology and Discussion

Toe walking is the absence or limitation of heel strike during the normal gait cycle. Contractures may or may not be present, and physical examination findings are significant for reduced ankle range of motion.1 Toe walking can be a simple habit that develops at an early age when a child starts to walk. Toddlers up to 3 years of age often toe walk on occasion, but toe walking beyond this age is considered abnormal. Toe walking associated with tight leg muscles or incoordination is concerning. Toe walking can be commonly related to the following conditions:

Cerebral palsy (CP). Toe walking occurs in 50% of children with CP, making it the most common cause of toe walking. CP is caused by any perinatal injury or abnormal development of the brain that leads to disorders of muscle tone (which can present with toe walking) or disorders of posture and movement. Toe walking with CP may be unilateral or bilateral. Physical examination will show spasticity or catching of the joint; clonus sometimes is elicited.

Muscular dystrophy (MD) or congenital myopathies. MD is a genetic disorder in which progressive damage to and weakness of muscles occurs over time. This disorder sometimes can present with toe walking, which develops over time. The child initially has a normal gait. MD is characterized by proximal muscle weakness (weakness of the hips) with normal calf and distal strength. Children with MD usually start walking with a flat-footed gait that progresses to toe walking at approximately 3 to 6 years of age. Heel cord contracture results in decreased passive dorsiflexion of the ankles, which is almost always bilateral.

Autism spectrum disorders (ASD). About 19% of children with an ASD exhibit intermittent toe walking for a minimum of 6 months. Reduced ankle mobility is rare in these children.

Additionally, hereditary sensorimotor neuropathies or focal dystonia are rare cause of toe walking in children. One study has linked idiopathic toe walking with other developmental concerns, including speech and language difficulties4; the authors theorize that toe walking may be attributed to a sensory processing difficulty or possibly a vestibular disorder.

Idiopathic toe walking, also called habitual toe walking,2 is a diagnosis of exclusion when no other pathologic cause is identifiable. It has been speculated that toe walking could be related to nerves, muscles, a combination of both, or another unknown factor.

One of the largest published studies of toe walking was done in Sweden and enrolled more than 1,400 children.2 At participants’ 5½-year routine checkup, parents were asked about toe walking in their child. The results of this study showed that nearly 5% of all participants had toe walked at some time, but by 5½ years of age, fewer than half of children in the study who had toe walked were still doing so, typically spending about 25% of the time on their toes. The other children generally toe walked for 1 to 2 years and then spontaneously began to walk with a normal gait. Of the children in the study with a diagnosed cognitive or neuropsychiatric disorder (such as autism), 41% either still toe walked at 5½ years of age or had a history of toe walking.

A detailed history and thorough physical examination help distinguish among the different etiologies of toe walking. Williams and colleagues3 have created an online Toe Walking Tool questionnaire to assess idiopathic toe walking and exclude medical conditions that could cause it.

In most cases, idiopathic toe walking ceases spontaneously. Treatment options have included botulinum toxin type A injections, physical therapy, serial casting, gait retraining, and molded ankle-foot orthoses, none of which have proven to be effective. In certain children, these treatments might speed the resolution of toe walking. Heel-cord lengthening surgery appears to be effective in eliminating or improving toe walking in most patients who do not respond to conservative treatment.

References

1. Oetgen ME, Peden S. Idiopathic toe walking. J Am Acad Orthop Surg. 2012; 20(5):292-300.

2. Engström P, Tedroff K. The prevalence and course of idiopathic toe-walking in 5-year-old children. Pediatrics. 2012;130(2):279-284.

3. Williams CM, Tinley P, Curtin M. The Toe Walking Tool: a novel method for assessing idiopathic toe walking children. Gait Posture. 2010;32(4):508-511.

4. Pernet J, Billiaux A, Auvin S, et al. Early onset toe-walking in toddlers: a cause for concern? J Pediatr. 2010;157(3):496-498.