Toe Walking in Children

Toe Walking is defined as the failure of the heel to contact the floor at the onset of stance during the gait cycle, resulting in a bilateral toe to toe gait.

Idiopathic Toe Walking (ITW), as its name implies, refers to the manifestation of this gait pattern without a known underlying pathological cause. This is a diagnosis of exclusion, in which other conditions causing an equinus gait have been ruled out.

Differential Diagnosis

In considering differential diagnosis, it is important to take into account any potential underlying neuromuscular or musculoskeletal conditions. Toe walking may be caused by Cerebral Palsy, congenital contracture of the Achilles tendon or paralytic muscular disorders such as Duchenne Muscular Dystrophy. Idiopathic Toe Walking may be associated with developmental disorders such as Autism or other myopathic or neuropathic disorders.

The majority of disorders causing toe walking can be ruled out through the history and physical examination, resulting in a diagnosis of Idiopathic Toe Walking. A child with a diagnosis of ITW will present with a normal neurological exam with respect to muscle tone, reflexes, sensation and strength. The child may or may not have a passive limitation in ankle dorsiflexion. Idiopathic Toe Walking will always exhibit bilateral and symmetrical presentation, as opposed to some other neurologic conditions which may cause unilateral or asymmetric toe walking.

Background

A study by Sobel et al revealed that the majority of child who present with Idiopathic Toe Walking had a normal birth weight, walked on time, began to toe walk immediately in their gait development, stood mostly in plantigrade (feet flat), were able to demonstrate heel-toe gait when instructed, and only toe walk intermittently.

It is theorized that ITW may be one element of a more global neurodevelopmental condition, since many of these children present with other diagnoses concomitantly. Many young children are recognized as having a toe-walking tendency when they first start to walk, which is not considered an anomaly. However, if this pattern persists beyond 2-3 years of age, it should be labeled as ITW in the absence of any other pathology. A study by Le Cras et al reported a higher incidence of ITW in males as compared to females, and that a family history of ITW often exists.

Sensory Connection

Idiopathic toe walking may be linked to hyper or hyposensitivity. Some children may not like the feeling of different surfaces on their bare feet, which cause them to rise up on their toes to avoid having the full surface of their feet contracting floor. For children who are seeking more input, toe walking increases the force of impact felt during ambulation, as the ground reaction force is distributed through a smaller surface area at the metatarsal heads.

Exam/Assessment

In order to best determine an ideal treatment protocol, a comprehensive history should be taken. Children who ambulate later or skip developmental milestones which limit weight bearing, often present with ITW.

• Does the child toe walk when wearing shoes?
• Do you notice more or less toe walking when ambulating barefoot on different surfaces?  For instance sand at beach, grass at park, hard wood floor, carpet.
• Is the child able to achieve and maintain full range of motion at ankle?
• Evaluate passive vs active range of motion of gastrocnemius, soleus and hamstring complex.
• Assess the child’s overall lower extremity biomechanics from position of pelvis, knees and feet.
• Assess child’s static vs dynamic arch formation of foot. Often times children with ITW will have weak intrinsic plantar muscles, and use toe walking to compensate.

Treatment Ideas

1. Passive Range of Motion

Calf Stretch (Ankle dorsiflexion/plantarflexion): With the child lying on back or seated, hold child’s foot in hand. Apply light pressure flexing foot up towards child’s head. Once you feel resistance, hold for 15 seconds, alternate feet and repeat stretch.

Hamstring (Knee flexion/extension): With the child lying on back or seated, with opposite knee bent or flat on floor, lift child’s leg with knee straight until you feel resistance. Hold for 15 seconds, alternate legs and repeat stretch.

2. Active Range of Motion

Have child stand barefoot on dynamic surface. The dyna-disc, incline wedge, and balance board are all great tools!

As child shifts body weight to maintain balance, the child will experience an active stretch of the affected musculature. 

3. Strength 

Intrinsic Plantar Muscles: you can target these small muscles by picking up objects with toes. Try “toe basketball” lifting small pompoms with feet and placing into cup to score! 

Anterior Compartment Musculature: we can promote active dorsiflexion with “bean bag elevators” using soft bean bags.  Allow child to flex ankle to target lower body strength and active range of motion of ankle and foot musculature.

Navigating seated Scooter Board helps to engage anterior compartment musculature and provide additional weight bearing element to heel as child propels forward.

Stepping or jumping over hurdles or cones offer additional ways to activate trunk and leg musculature!

Abdominal Musculature: dynamic activities which challenge core strength include seated/standing balance on dyna-disc or balance board. 

Sitting on therapy ball or peanut ball shifting weight back and front, side to side will help activate abdominals and obliques.

Bridging exercises are great not only for trunk strengthening, but utilizing the dyna disc as seen above also incorporates arch activation!

4. Weight-Bearing Activities

Encourage barefoot standing using a variety of textures, promote squat to stand with fun activities to facilitate weight bearing. We always love dyna-disc or tactile discs for these activities!

Squats on the foam balance pad are great for lower extremity strength, stability and weight bearing through full plantar surface of foot!