Idiopathic toe walking: for therapists

Idiopathic  toe walking (ITW) is a developmental gait disorder characterized by the child habitually walking on the toes, in the absence of any specific muscular or neurological disorder.   

General characteristics

Habitual toe walkers usually adopt a toe-walking gait from the onset of independent walking. They walk independently bilaterally on the  toes within the typical age range (Sala et al 1999, Sobel et al 1997)  

The child may spontaneously walk with a heel strike gait some of the time, and most children can adopt a heel-strike gait pattern when instructed to do so. However, the pattern of muscle activation differs from that of typically developing children (Crenna 2005).  (See Gait Kinematics and EMG studies below.) 

The majority stand plantigrade (Sobel et al 1997).  They tend to stand with the feet wide apart and turned out. (Versfeld 2012)

Muscle tone, deep tendon reflexes, and sensation are normal. (Sala et al, 1999.) Muscle strength and endurance, when tested in functional movements patterns is often poor. (Versfeld 2016)

Children who toe walk often have family members who also toe walk, with a familial incidence of up to 32% (Hemo et al, 2006) 

Etiology

The etiology of idiopathic toe walking is not known.  The tendency to walk on the toes is usually ascribed to shortening of the calf muscles and Achilles tendon. However,  although some children have marked restriction of dorsiflexion, in many children the degree of restriction is only mild. 

A study by Furrer et al (reported by Sala) noted children who are assessed at a younger age are less likely to have limitation of dorsiflexion than older children, lending support to the idea that the child develops tightness in the tendo achilles a result of persistent toe walking, rather than this tighness being the cause of the toe walking.  

Sensory modulation disorders have been proposed as a reason for a child walking on the toes. However there is no evidence for this claim (Williams, 2010)

Infants learning to walk do not have a consistent heel-toe gait: this is only established after  several months of independent walking experience as the child learns to control the many different aspects of the stance and swing phases of a mature gait pattern. The question that has not been addressed by researchers is why some children do not develop a typical heel-toe sequence during the stance phase of walking. 

Clinically children who present with toe walking in most cases also have generalised joint hypermobility, with associated muscle weakness and paradoxical tightness in two joint muscle and fascial structures of the lower quadrant.(Versfeld 2016)  This gives rise to restricted range of hip adduction and lateral rotation with the hip in extension which has an affect on lower limb alignment in walking. 

Most children with generalized joint hypermobility walk with a heel-toe gait. So the question remains as to why some children toe walk while others do not. 

Children on the autistic spectrum have a higher incidence of toe walking than neuro-typical  children (Brown 2011).  This may be related to the postural  and coordination difficulties experienced by children on the autistic spectrum (Bhat et al 2011, Wyat et al 2011).  Generalised joint hypermobility is also common in ASD (Shetreat-Klein  2014).

Gait kinematics in toe walkers

Crenna et al (2005)  used kinematic, kinetic and EMG analysis to compare the spontaneous heel-contact gait patterns of 13 children classified as habitual toe walkers (HTWs) and age-matched controls.  "In the HTWs, the incidence of spontaneous heel-contact strides during a single recording session ranged from 15% to 92%, with no correlation with age, passive ankle joint excursion, walking speed and trial order." 

"Hallmarks of the heel-contact strides were premature heel-rise, reversal of the second rocker, relative shortening of the loading response and anticipation and enhancement of the electromyographic (EMG) activity normally observed in the triceps surae (TS) during the first half of the stance phase. This variant of the locomotor program is different from the walking patterns observed in normally developing toddlers and children with cerebral palsy (CP). It does not necessarily reflect a functional adaptation to changes in the rheological properties of the muscle–tendon complex."

Crenna et al also looked at the difference in EMG recordings of the muscle action in HTW when walking with a  heel contact gait.  "The most striking changes marking the heel-contact gait of HTWs were seen at 10–30% of the stride cycle. Dynamic EMG studies have shown that during this phase the forward rotation of the shank and the simultaneous progression of the COP are normally controlled by a lengthening contraction of the TS (the TSa component), with EMG silence on the antagonists TA  (Crenna 2001) 

 "In the heel-contact strides of HTWs, TSa proved to be most often prematurely recruited, with an increase in relative amplitude, and frequently followed by a definite silent period, while the reciprocal EMG silence was usually preserved. The prematurely augmented plantar-flexor torque resulting from these changes might well be responsible for the rapid progression of the COP toward the metatarsal heads and the shortening of the weight-acceptance phase. Moreover, the enhanced TSa in the bi-articular knee-flexor gastrocnemii was congruent with a premature rise of the heel and early plantar-flexion of the foot. Indeed, TSa activity attained a peak between 13% and 16% of the stride, which, taking into account the electro-mechanical delay [29], is consistent with the achievement of maximum mechanical effect at around 20% of the stride. The increased braking of the forward rotation of the shank, produced by the augmented TSa component, may produce knee hyperextension. The absence of hyper- extension in the children tested indicates a protective action of the gastrocnemii and possibly of the hamstrings, but the latter was not analysed in this study. "

Differential diagnosis 

Mild diplegic cerebral palsy.  There are differences in the patterns of muscle recruitment, and in particular the co-activation of antagonisitc muscles is commonly seen in CP but not in ITW (Policy 2001).  Muscle tone, deep tendon reflexes, and sensation are normal. (Sala 1999)
Duchenne muscular dystrophy
Spinal conditions such as syringomyelia  can present with equinus contractures and/or toe walking
Tethered cord syndrome may present as gait abnormalities and subtle neurological signs.  
Muscular skeletal disorders of the lower limbs (injuries, infection) present as acute onset of toe walking, usually in one leg. Idiopathic toe walking does not have an acute onset and is always bilateral. 

Intervention strategies

 In a review idiopathic toe walking Sala et al concluded: The efficacy of different treatment modalities is unclear. Improvement has been reported with exercises, serial casting,and surgery.

Comparisons across studies are difficult because clinical criteria for the use of each type of treatment are usually not provided. Generally, surgical intervention is used for only the worst cases when significant plantarflexor contractures are present.

​Hagland reported on a series of patients who had received one injection of botulinum toxin: 

"The purpose of this study was to investigate whether botulinum toxin A (BTX) improves the walking pattern in ITW as examined with 3-D gait analysis. 

"A consecutive series of 15 children (aged 5–13 years) were enrolled in the study. The children underwent a 3-D gait analysis prior to treatment with a total of 6 units/kg bodyweight Botox? in the calf muscles and an exercise program. The gait analysis was repeated 3 weeks and 3, 6, and 12 months after treatment. A classification of toe-walking severity was made before treatment and after 12 months.The parents rated the perceived amount of toe-walking prior to treatment and 6 and 12 months after treatment. 
Eleven children completed the 12-month follow-up. The gait analysis results displayed a significant improvement, indicating decreased plantarflexion angle at initial contact and during swing phase and increased dorsiflexion angle during midstance at all post-treatment testing instances. According to the parents’ perception of toe- walking, 3/11 children followed for 12 months had ceased toe-walking completely, 4/11 decreased toe-walking, and 4/11 continued toe-walking. After 6–12 months, the toe- walking severity classification improved in 9 of the 14 children for whom data could be assessed." 

​Hagland (2010)concluded that a single injection of BTX in combination with an exercise program can improve the walking pattern in children with ITW seen at gait analysis, but the obvious goal of ceasing toe-walking is only occasionally reached.

Serial casting has been shown to be effective in two recent studies. Fox et al (2006) reported improvement in 60 % of cases treated by serial casting. 
 

Research update 2018

Engström P, Tedroff K. Idiopathic Toe-Walking: Prevalence and Natural History from Birth to Ten Years of Age. J Bone Joint Surg Am. 2018 Apr 18;100(8):640-647. doi: 10.2106/JBJS.17.00851. PubMed PMID: 29664850.

BACKGROUND: Children with idiopathic toe-walking, a common pediatric condition, walk some or all of the time on their toes. This condition often causes parental concern, with repeated medical contacts and a range of interventions including stretching, casts, injection of botulinum toxin A, and surgical procedures. The purpose of this cohort study was to document the natural history of this condition.

METHODS: In a population-based cohort of 1,401 healthy 5.5-year-old Swedish children, we found the prevalence of idiopathic toe-walking to be approximately 5% (63 of 1,401). Of the 63 children who had ever been a toe-walker, 26 still were at the age of 5.5 years and were followed in the current study at 8 and 10 years of age. At the 8-year follow-up, parents were asked by telephone whether their child had received any treatment or diagnosis since the 5.5-year assessment, as well as to what extent (approximately 25%, 50%, 75%, or 100% of the time) the child still walked on the toes. At the visit when the children were 10 years of age, their parents were asked the same questions. All 26 children also underwent a neurological examination and an orthopaedic examination focusing on the lower extremities.

RESULTS: At 8 years of age, 6 of 26 children had ceased toe-walking, and by the age of 10 years, 50 (79%) of the original 63 patients had spontaneously ceased toe-walking. Idiopathic toe-walking did not result in contractures of the triceps surae. One subgroup of children displayed early contracture of the ankle and should thus not be considered idiopathic toe-walkers. Four of the children who still toe-walked at the age of 10 years demonstrated some neurodevelopmental comorbidity.

CONCLUSIONS:  By the age of 10 years, 79% of the children who have ever been a toe-walker spontaneously develop a typical gait, without intervention or contractures of the ankle dorsiflexion. The diagnosis of short tendo Achilles should be retained as a separate diagnosis as there is a subset of children with this entity who should be treated early in childhood. Neurodevelopmental comorbidities are common among those who continue to toe-walk.



Davies K, Black A, Hunt M, Holsti L. Long-term gait outcomes following conservative management of idiopathic toe walking. Gait Posture. 2018 May;62:214-219. doi: 10.1016/j.gaitpost.2018.02.014. Epub 2018 Feb 14. PubMed PMID: 29571089.

BACKGROUND: Idiopathic toe walking  is a diagnosis of exclusion characterized by a persistent toe-toe gait pattern after three years of age. Treatment for toe walking includes physical therapy, orthotics, casting, Botulinum Toxin A injection into gastrocnemius/soleus muscles, and/or surgery; yet, little evidence exists regarding long-term treatment effects.

RESEARCH QUESTION: The objective of this study was to explore the differences in longer-term gait outcomes and severity of idiopathic toewalking between children treated actively with casting or inactively following recommendations for stretching.

METHODS: Forty-three adolescents and young adults (14.3-28.8 years; 21 females, 22 males) who had participated in an idiopathic toewalking classification study as children, returned for repeat physical examination and three-dimensional computerized gait analysis (13.4 years follow-up, range 9.4-17.8 years); 23 participants had received active treatment with casting and ankle foot orthotics ± Botulinum Toxin A injection as children and 20 participants had received inactive treatment with recommended stretching exercises. Gait analysis data were compared retrospectively from baseline to follow-up using analysis of variance; toe walking severity was compared using a Wilcoxin Signed-Rank Sums test.

RESULTS: Ankle angle at initial contact, peak dorsiflexion in stance, and toe walking severity improved significantly in the active treatment group only at follow-up. Significant improvement in peak ankle power and timing of ankle kinematics and kinetics in the gait cycle were found in both groups; however, greater changes occurred in the active treatment group. Both groups showed significantly improved internal plantar flexor moments, whereas knee extension increased in stance and passive ankle dorsiflexion decreased in both groups at follow-up (p = 0.001). Intermittent toe walking was reported in 49% (21/43) of participants at follow-up.

SIGNIFICANCE: The results of this study suggest that improvement in ankle kinematic timing and ankle kinetic gait analysis variables is sustainable, independent of conservative treatment for idiopathic toe walking in childhood.


Haynes KB, Wimberly RL, VanPelt JM, Jo CH, Riccio AI, Delgado MR. Toe Walking: A Neurological Perspective After Referral From Pediatric Orthopaedic Surgeons. J Pediatr Orthop. 2018 Mar;38(3):152-156. doi: 10.1097/BPO.0000000000001115. PubMed PMID: 29309384.

BACKGROUND: Toe walking (TW) in children is often idiopathic in origin. Our purpose was to determine the incidence of a neurological etiology for TW in patients seen in the neurology clinic after referral from pediatric orthopaedic surgeons.

METHODS: We performed an Institutional Review Board approved retrospective review of 174 patients referred to the neurology clinic from orthopaedic surgeons at an academic pediatric tertiary care center between January 2010 and September 2015. Medical records were reviewed and data recorded including pertinent family history, birth history, age of initial ambulation, physical examination findings, and workup results including neuroimaging, neurophysiological studies, and findings of genetic testing and tissue biopsy.

RESULTS: Sixty-two percent (108/174) of patients were found to have a neurological etiology for TW. Final pathologic diagnoses were: 37% (40/108) previously undiagnosed cerebral palsy (CP), 16.7% (18/108) peripheral neuropathy, 15.7% (17/108) autism spectrum disorder, 13.9% (15/108) hereditary spastic paraparesis, 8.3% (9/108) attention deficit hyperactivity disorder, 5.6% (6/108) syndromic diagnosis, and 2.8% (3/108) spinal cord abnormality. Ankle equinus contractures were noted in idiopathic and neurological patients and did not indicate a pathologic origin. Seventy-one percent of unilateral toe walkers and 32% of bilateral but asymmetric toe walkers were diagnosed with CP (P<0.001). Twenty-six percent of 145 brain magnetic resonance imaging studies diagnosed CP. Of the 125 (72%) with spinal imaging, 3 had spinal pathology to account for TW. Fourteen percent of 87 subjects with an electromyography/nerve conduction study had abnormal results indicating a peripheral polyneuropathy.

CONCLUSIONS: An underlying pathologic diagnosis was found in 62% of patients referred to neurology for TW. A concerning birth history, delayed initial ambulation, unilateral TW, upper or lower motor neuron signs on examination, or behavioral features may suggest a pathologic diagnosis. Ankle contracture is not predictive of an abnormal diagnosis and can be found in idiopathic patients. CP, peripheral neuropathy, autism spectrum disorder, and hereditary spastic paraparesis are the most common pathologic diagnoses identified in our population.

LEVEL OF EVIDENCE: Level III-retrospective cohort.


Research published in 2016

Williams CM, Michalitsis J, Murphy AT, Rawicki B, Haines TP. Whole-Body Vibration Results in Short-Term Improvement in the Gait of Children With Idiopathic Toe Walking. J Child Neurol. 2016 Apr 12. pii: 0883073816643405. [Epub 
ahead of print] PubMed PMID: 27071469.

McMulkin ML, Gordon AB, Tompkins BJ, Caskey PM, Baird GO. Long term gait outcomes of surgically treated idiopathic toe walkers. Gait Posture. 2016 Feb;44:216-20. doi: 10.1016/j.gaitpost.2015.12.013. Epub 2015 Dec 18. PubMed
PMID: 27004661.

Szopa A, Domagalska-Szopa M, Gallert-Kopyto W, Kiebzak W, Plinta R. Effect of  a nonsurgical treatment program on the gait pattern of idiopathic toe walking: a case report. Ther Clin Risk Manag. 2016 Feb 10;12:139-46. doi:
10.2147/TCRM.S95052. eCollection 2016. PubMed PMID: 26937193; PubMed Central PMCID: PMC4762432.

Pomarino D, Ramírez Llamas J, Pomarino A. Idiopathic Toe Walking: Tests and Family Predisposition. Foot Ankle Spec. 2016 Feb 12. pii: 1938640016630056. [Epub ahead of print] PubMed PMID: 26872463.

Baber S, Michalitsis J, Fahey M, Rawicki B, Haines T, Williams C. A Comparison of the Birth Characteristics of Idiopathic Toe Walking and Toe Walking Gait Due to Medical Reasons. J Pediatr. 2016 Apr;171:290-3. doi: 10.1016/j.jpeds.2015.12.069. Epub 2016 Jan 16. PubMed PMID: 26787375.

Fanchiang HD, Geil MD, Wu J, Ajisafe T, Chen YP. The Effects of Walking Surface on the Gait Pattern of Children With Idiopathic Toe Walking. J Child Neurol. 2016 Jan 5. pii: 0883073815624760. [Epub ahead of print] PubMed PMID:
26733505.

Ruzbarsky JJ, Scher D, Dodwell E. Toe walking: causes, epidemiology, assessment, and treatment. Curr Opin Pediatr. 2016 Feb;28(1):40-6. doi: 10.1097/MOP.0000000000000302. PubMed PMID: 26709689. 

O'Sullivan R, O'Brien T. Idiopathic Toe Walking: A Gait Laboratory Review. Ir  Med J. 2015 Jul-Aug;108(7):214-6. PubMed PMID: 26349353.Rreferences 

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​Crenna, P., Fedrizzi, E., Andreucci, E., Frigo, C., & Bono, R. (2005). The heel-contact gait pattern of habitual toe walkers. Gait and Posture 21, 311-317

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Fox A, Deakin S, Pettigrew G, Paton R. (2006) Serial casting in the treatment of idiopathic toe-walkers and review of the literature.  Acta Orthop Belg. 2006 Dec;72(6):722-30

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Haglund-a, Y. (2010). Does botulinum toxin A improve the walking pattern in children with idiopathic toe-walking? Journal Of Pediatric Orthopedics, 301-308.

Hemo Y, Macdessi SJ, Pierce RA, Aiona MD and Sussman MD. Outcome of patients after Achilles tendon lengthening for treatment of idiopathic toe walking.  Journal of Pediatric Orthopedics. 2006; 26:336-340

Policy, J. F., Torburn, L., Rinsky, L. A., Rose, J., & D, P. (2001). Electromyographic Test to Differentiate Mild Diplegic Cerebral Palsy and Idiopathic Toe-Walking. Journal of Pediatrics 21: 784-789.

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