"Idiopathic Toe Walking"-Issue 10

All children will experiment by walking on their “tippy toes” at some point during development.  So when then does this playful experiment become something that should be looked into a little further?  Most experts will recommend that if your child spends >25% of their walking time up on their toes and are over the age of two they should be evaluated by a physician.

Toe walking can occur for many reasons, and a thorough exam should be performed to determine the cause and prescribe the most appropriate treatment. Your physician should first rule out any serious neuromuscular or orthopedic problems such as: cerebral palsy, injuries to the spinal cord, or paralytic muscle diseases including muscular dystrophy, that could be causing this tip toe walking pattern.  

Idiopathic toe walking is only diagnosed when your child demonstrates a persistent tip toe walking pattern, and all potential neurologic, orthopedic and psychiatric causes have been completely ruled out. This term implies that the toe walking occurs in an otherwise healthy child and that there is no disease or dysfunction creating the abnormal walking pattern.  It is estimated that idiopathic toe walking occurs in up to 24% of children, and that there is a family history of toe walking in 30-71% of children diagnosed.

Studies show that occasionally this diagnosis can be tied to language delays and learning disabilities.  If you begin to notice any delays in your child’s ability to learn, communicate, or interact socially, requesting a developmental assessment from your physician may be appropriate.  A child with idiopathic toe walking may also have some form of a sensory processing dysfunction.  This means that your child may walk on his/her toes due to a hyper or hyposensitivity in their feet.  Your child may not like the feeling of different surfaces on their bare feet, causing them to rise up on their toes to decrease the amount of contact their feet have with the floor.  In this case, requesting a sensory profile/assessment may be appropriate.

Idiopathic toe walking first appears when the child learns how to walk.  Often the child can walk flatfooted when asked to do so, but quickly returns to the tip toe pattern as their preferred method of movement.  Over time, walking in this position will result in tightness of the calf muscles and limited motion of the ankle/foot. The longer the child walks in this position, the greater the loss of motion.  This not only places your child at an increased risk for ankle injuries as a child, but is also statistically tied to increased foot pain and pathology as an adult.  If the calf tightness is not addressed early on, it can develop into a “muscle contracture”.  This is when the muscle becomes physically shortened after being too tight for too long and can no longer be stretched out by conservative means.

Early identification and treatment of children with idiopathic toe walking is needed to prevent the development of calf tightness, limited motion of the ankle, and development of permanent abnormalities in how they walk.  Physical therapy is generally recommended to address calf tightness, leg weakness, balance deficits, provide sensory feedback and assess the need for orthotics.  When started early on, therapy has proven to be successful in correcting toe walking.  Older children with idiopathic toe walking may not respond as well to physical therapy and may also require a series of casts or night splints to help correct the problem.  In severe cases, such as the development of contractures, the use of botox injections or surgical intervention to help lengthen the muscle tendons may be recommended. 

For more information about this topic and others, contact your local physician or physical therapist.

Physical Therapy Quick Tips:

·      Daily passive stretching for the calf and hamstring muscles is recommended frequently throughout the day

·      Proper shoes are a must!  Lace up tennis shoes will give your child feedback about where their feet are and provide additional support for their ankles, making it easier to walk with flat feet

o Squeaky shoes may be helpful.  These shoes make a sound only when your child walks with his/her feet flat on the floor providing them with a squeaky sound to encourage correct walking (Caution to parents: you will want to do this in conjunction with the other tips as this sound may get a little too much too handle on a long day)

·      Take time to SLOW DOWN and LOWER DOWN: Your child’s little legs sometimes have a hard time keeping up with your pace, causing them to rise up on their toes.  When this is combined with trying to hold your hand—which may be a big stretch to reach for, it may be difficult to walk flat footed.  Take the time to lower your hand and slow your pace to help encourage a proper walking pattern 

References:

1. Le Cras S, Bouck J, Brausch S, Taylor-Hass A; Cincinnati Children's Hospital Medical Center: Evidence-based clinical care guideline for Management of Idiopathic Toe Walking, Guideline 040, pages 1-17, February 15, 2011.

2.Eiff M, Steimer E; What is the appropriate evaluation and treatment of children who are toe walkers? The Journal of Family Practice. 2205; 55(5):1-3.

3. Englebert R et al. Idiopathic toe-walking in children, adolescents, and young adults: a matter of local or generalized stiffness? BMC Musculoskeletal Disorders. 2001. 12(61):1-8.

4. Zimbler S. Idiopathic Toe Walking: Current Evaluation and Management. Children's Hospital. 2009. 98-100.