Diseases & Conditions
Toe Walking
Toe walking is a way of walking in which a child walks on the balls of the feet. The heels do not touch the ground. Toe walking is common in children who are learning to walk. After age 2, however, most children stop toe walking. They start to walk with a normal heel-to-toe pattern.
In very rare cases, toe walking that continues after age 2 may be a sign of a medical condition. However, in most children, persistent toe walking is idiopathic. This means that the exact cause is not known.
Some older children may continue to toe walk out of habit. In other children, they may continue to toe walk because the muscles and tendons in the calves have become tighter over time.
Treatment for persistent toe walking often includes casting or bracing. These treatments help stretch the muscles and tendons in the calves. They also encourage a normal walking pattern, or gait.
Anatomy of the Calf
The calf is made up of two major muscles:
- Gastrocnemius muscle. This is the larger calf muscle. Its two parts form the bulge you can see under the skin.
- Soleus muscle. This is a smaller, flat muscle. It lies under the gastrocnemius muscle.
Both muscles join near the bottom of the calf. They then become the Achilles tendon. The Achilles tendon attaches to the calcaneus (heel bone).
When your calf muscles tighten, the Achilles tendon pulls on the heel.
In some children who toe walk, this muscle-tendon combination may be shorter at birth. In other children, it may become shorter over time. This tightness can keep the child from placing the heels on the ground and walking flat-footed.
However, in most children who toe walk, the muscles and tendons are long enough to allow the heels to touch the ground. These children can walk flat-footed when they are reminded to do so.
Causes of Toe Walking
In most children, toe walking is idiopathic. This means that the exact cause is unknown. When these children are checked out by a doctor, their physical and neurological exams are normal.
Medical Causes
In a smaller number of children, persistent toe walking can be a sign of another medical condition. These conditions may include:
- Cerebral palsy
- Muscular dystrophy
- A spinal cord abnormality
- Nerve conditions, such as Charcot-Marie-Tooth disease (CMT); CMT is usually an inherited condition
Children with autism-related conditions toe walk more often than children who are developing normally. However, there is no direct link between toe walking and autism.
Children with sensory issues may also toe walk. For example, they may not like the texture or temperature of the floor against their feet.
Symptoms of Toe Walking
Most young children who toe walk can walk flat-footed when asked to do so.
Many older children who continue to toe walk cannot walk with their heels down. This is more common in children over age 5 These children may have trouble wearing certain shoes. They may also have problems taking part in sports or other activities.
Some children who toe walk have no specific complaints. However, their parents may still have concerns. They may wonder how toe walking could affect their child's function as a teenager or adult.
Doctor Examination for Toe Walking
Medical History
Your child's doctor will begin by asking questions about your child's health and development. Questions may include:
- Were there any problems during the pregnancy?
- Was your child born prematurely?
- How old was your child when they reached milestones such as smiling, sitting, and walking?
- When did the toe walking start? Did it begin when your child first started walking? Or did it begin at an older age?
- Does your child toe walk on both sides or only one side? Toe walking on only one side may be more concerning since it can sometimes be a sign of a neurological problem.
- Is there a family history of toe walking?
- Is there a family history of neurological or muscle disorders?
- What percentage of the time does your child walk on their toes?
- Can your child walk flat-footed when asked?
- Does your child have foot or leg pain?
- Does your child have weakness in the legs?
- Does your child have trouble keeping up with other children of the same age?
Physical Examination
The physical exam usually begins with the doctor watching your child walk.
The doctor will first ask your child to show their usual walking pattern, including walking on the toes.
The doctor will then ask your child to show their "best" walk. This means walking as flat-footed as possible.
The doctor will look at the toe walking and how smoothly your child walks. The doctor may also ask your child to run and hop. Your child may be asked to sit on the floor. They may then be asked to stand up without using their hands.
During the physical exam, your child's doctor will also:
- Check the feet for abnormalities. This includes differences between the left and right feet.
- Look for differences in leg length.
- Compare the size of the thighs and calves.
- Check whether one or both calf muscles are tight. The doctor will ask your child to move the feet and ankles in several different ways.
- Check the range of motion in the hips and knees.
- Look for skin changes or other abnormalities in the legs and back.
Tests
Neurological Exam
Simple neurological tests can help the doctor find out if a problem with your child's nervous system could be causing the toe walking. Some neurological conditions include cerebral palsy or neuropathies such as Charcot-Marie-Tooth disease.
Some children with autism toe walk. Some children with sensory integration disorder also toe walk.
The exam will be adjusted for your child's age and developmental level. It will also depend on your child's ability to cooperate.
During the neurological exam, the doctor will:
- Check for contracture or excessive tightness of the muscles of the arms or legs.
- Check the strength of the major muscles.
- Check reflexes by tapping a small rubber hammer or fingertip on different areas of the body.
- Test sensation, or feeling, in the arms and legs.
Other Tests
Idiopathic toe walking is a diagnosis of exclusion. This means that other possible causes must first be ruled out. The doctor uses your child's medical history and physical exam to look for other causes.
Sometimes other tests are needed. These may include X-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, nerve and muscle tests, or genetic testing. Some nerve and muscle tests use electrode patches placed on the skin. Others may use small needles.
Treatment for Toe Walking
Treatment for toe walking depends on several factors, including:
- Your child's age
- Whether your child can walk flat-footed
Nonsurgical Treatment
For children who are 2 to 5 years old and can walk flat-footed, treatment always begins without surgery.
Nonsurgical treatments may include:
- Observation. Your child's doctor may recommend watching your child over time. This may include regular office. If your child is toe walking out of habit, the toe walking may stop on its own.
- Serial casting. Your child's doctor may place a series of short leg walking casts on your child's legs. The casts slowly stretch and lengthen the muscles and tendons in the calves. They may also help break the habit of toe walking. Serial casting is usually done over several weeks.
- Bracing. An ankle-foot orthosis (AFO) can help stretch and lengthen the muscles and tendons. An AFO is a plastic brace that extends up the back of the lower leg. It holds the foot at a 90° angle. Bracing is usually used for a longer period of time than casting. It is often worn for months rather than weeks.
- Botox therapy. Some children have a neurological condition that causes increased muscle tone. For these children, an injection of botulinum A toxin (Botox®) may be used to relax the calf muscles for a short time. This can make it easier to stretch the muscles during serial casting or bracing.
Surgical Treatment
In children over age 5 who toe walk, the calf muscles and Achilles tendons become very tight. In some children, that tightness makes it impossible to walk flat-footed.
For these children, the doctor may recommend surgery to lengthen the Achilles tendons. Lengthening the tendons improves motion. It also allows the foot and ankle to work better.
The part of the tendon that needs to be lengthened depends on wthe child's ankle motion. The doctor will check whether the child's foot can be placed flat at the ankle when the knee is bent.
There are several surgical techniques that can lengthen different areas of the tendon. Your child's doctor will talk to you about which technique is best for your child.
The procedure is usually done on an outpatient basis. This means your child usually does not need to stay overnight in the hospital.
After the tendons are lengthened, your child will still be asleep. The doctor will place short leg walking casts on your child's legs. These casts are usually worn for 4 to 6 weeks.
Recovery
Physical therapy is usually recommended. After surgery, physical therapy usually does not begin until the walking casts have been removed.
Outcome
Most children improve over time. They are able to take part in normal activities and sports.
However, studies show that some children continue to toe walk even after treatment with serial casting or surgery.
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