Toe walking!

Toe walking is a normal stage in gait development, and typically resolves by ages 3-7 years-old. Persistent toe walking is associated with increased risk of ankle sprain, less efficient gait, muscle cramps, foot pain, and difficulty with shoe wear.

Prevalence is about 2% in children at age 5.5yo with normal neurological developmental history, but 41% in those with neuropsychiatric diagnoses and developmental delay.

We commonly assume or expect an underlying neuromuscular or neurological condition to be responsible for toe walking (CP, muscular dystrophy, spina bifida, autism spectrum disorder); however, though a diagnosis of exclusion, idiopathic toe walking (ITW) is relatively common and is the most common cause of toe walking overall.

  • ITW was previously thought to be exclusively due to habit, but there is now evidence for a neurological basis in some cases, so perhaps not as volitional as we thought!
  • ITW is associated with speech and language delay, abnormalities in executive functions, social skills, and in those with differences in motor control and sensory processing
  • Majority of patients with ITW begin walking at a normal age and can stand plantigrade, which does not exclude the diagnosis!

Spontaneous heel strike occurs 15-92% of the time (quite variable!), and sometimes under voluntary control in patients with toe walking.

Treatment is challenging! Observation is recommended if <2yo; if >2yo, PT is typically the first approach. Other considerations include orthotics, serial casting, chemical denervation, and surgical lengthening of the gastroc-soleus-Achilles complex. Recent systematic reviews (see here and here) most strongly support casting and surgery for resolution of symptoms.