Toe Walking

Toe walking is a walking pattern in which a youngster walks on the balls of his or her feet, with no touch with the ground at all. In children learning to walk, toe walking is very prevalent. Most youngsters outgrow toe walking after the age of two and begin walking in a regular heel-to-toe pattern.

Continuing to toe walk after the age of two may indicate an underlying medical problem in very uncommon circumstances. The vast majority of cases of chronic toe walking, on the other hand, are "idiopathic," meaning that the exact etiology is unknown. Older kids who continue to toe walk may do so out of habit or because their calves' muscles and tendons have tightened with time.

To assist stretch the muscles and tendons in the calves and encourage a normal gait, persistent toe walking is generally treated with a period of casting or bracing.

Cause

Toe walking is "idiopathic," meaning that the reason is unknown in the great majority of children. These children's physical exams and neurological tests are normal when they are examined by a doctor.

Medical Cause

Persistent toe walking can be an indication of an underlying medical issue in a tiny percentage of cases, such as:

• Cerebral palsy
• Muscular dystrophy
• A spinal cord abnormality

Although children with autism-related disorders toe walk more than children who are growing normally, there is no direct relation between the two conditions, and their toe walking could be due to sensory issues.

Symptoms

When asked to walk flat-footed, most young children who walk on their toes are able to do so. Many older children (typically those over the age of 5) who continue to toe walk are unable to walk with their heels down. These kids may have difficulty wearing shoes or participating in sports or recreational activities that require them to use roller skates or ice skates.

Some toe walkers have no problems, but their parents are concerned about the influence their walking pattern will have on their future function as teenagers and adults.

Treatment

Treatment for toe walking depends on a number of factors, including:

• The age of the child
• Whether the child is able to walk flat-footed

Non Surgical Treatment

Initial therapy is always nonsurgical for children aged 2 to 5 years old who are able to walk flat-footed.

Treatment options that aren't surgical include:

• Observation. For a period of time, your doctor may recommend merely monitoring your child with regular office visits. It may cease on its own if he or she is toe walking out of habit.
• Botox Therapy. An injection of botulinum A toxin (Botox®) may be used to temporarily weaken the calf muscles in certain patients—usually those with a neurologic condition that leads to increased muscular tone. This will make it easier for the muscles to stretch during casting or bracing.
• Serial Casting. To assist stretch and lengthen the muscles and tendons in the calf and break the toe-walking habit, your doctor may use a series of short leg walking casts. Serial casting takes place over a period of several weeks.
• Bracing. An ankle-foot orthosis (AFO) can assist in the stretching and lengthening of muscles and tendons. An AFO is a plastic brace that stretches up the back of the lower leg and maintains a 90-degree angle for the foot. Bracing is usually done for a longer amount of time than casting (months rather than weeks).

Surgical Treatment

The calf muscles and Achilles tendons in toe-walking children beyond the age of 5 may be so tight that walking flat-footed is impossible. A surgical procedure to lengthen the Achilles tendons may be recommended for these patients. The tendons can be lengthened to increase range of motion and improve foot and ankle function.

Whether or not the patient's foot can be positioned flat at the ankle with his or her knee bent determines whether the section of the tendon gets extended. To extend distinct sections of the tendon, a variety of procedures are performed. Your doctor will discuss which strategy is best for your child with you.

The technique is often performed as an outpatient treatment (no overnight stay). Your doctor will put your child's legs in short leg walking casts once the tendons have been stretched while he or she is still sleeping. Typically, these are worn for 4 to 6 weeks.

Recovery

After both surgical and nonsurgical treatment, physical therapy is frequently needed to assist the patient learn to walk flat-footed more regularly. After surgery, physical rehabilitation usually does not begin until the walking casts have been removed.