Downloaded from http://ep.bmj.com/ on June 15, 2015 - Published by group.bmj.
com
Education & Practice Online First, published on April 8, 2015 as 10.1136/archdischild-2014-307852
1
New Street Health Centre,
Barnsley, UK
2
Children’s Services, Leeds
Community Healthcare Trust,
Wortley Beck Health Centre,
Leeds, UK
Correspondence to
Dr Arnab Seal, Children’s
Services, Leeds Community
Healthcare Trust, Wortley Beck
Health Centre, Ring Road,
Leeds LS12 5SG, UK;
arnab.seal@nhs.net
Received 12 November 2014
Revised 14 February 2015
Accepted 4 March 2015
To cite: Sivaramakrishnan S,
Seal A. Arch Dis Child Educ
Pract Ed Published Online
First: [ please include Day
Month Year] doi:10.1136/
archdischild-2014-307852
Sivaramakrishnan S, et al. Arch Dis Child Educ Pract Ed 2015;0:1–4. doi:10.1136/archdischild-2014-307852
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
Fifteen-minute consultation: A child
with toe walking
Shobha Sivaramakrishnan,1 Arnab Seal2
ABSTRACT
Toe walking is a common developmental
phenomenon in young children. It is usually
benign and self-limiting. Toe walking can be a
presenting sign of some serious underlying
disorders and idiopathic toe walking is a diagnosis
of exclusion. Persistent toe walking can lead to
limited ankle dorsiflexion which may cause
functional problems. Specific interventions
depend on underlying cause and may range from
verbal reinforcement to serial casting and surgery.
TOE WALKING IN CHILDREN
Toe walking is a gait abnormality charac-
terised by absent heel strike and walking
predominantly on the forefoot. It may be
a normal developmental presentation
under 2 years of age. Persistent toe
walking, that is, lasting longer than
6 months after independent walking has
been established, merits further evalu-
ation for underlying neuromuscular or
developmental problems.1 Cerebral palsy,
Duchenne muscular dystrophy and
autism may all initially present with per-
sistent toe walking.
Children without any underlying
medical condition who walk on their toes
are referred to as idiopathic or habitual
toe walkers (ITW). A study from Sweden
reported a total prevalence of 4.9% of
idiopathic toe walking and 2.1% of per-
sistent toe walking in a cohort of
5.5-year-old children.2 In children who
had a neuropsychiatric diagnosis or devel-
opmental delay, the prevalence of a
history of toe walking (inactive) and per-
sistent toe walking (active) was 41.2%.2
A study in an orthopaedic clinic of per-
sistent toe walkers without known devel-
opmental problems showed significant
association with language delay and
motor delay.3
AETIOLOGY
Toe walking is associated with a variety of
pathological causes as outlined in table 1.
BEST PRACTICE
In general, diagnosis of ITW is one of
exclusion and requires thorough physical
examination and diagnostic work up where
indicated. Several possible aetiologies have
been postulated for ITW, such as defects in
sensory processing, short tendo-achilles,
different proportions of Type 1 muscle
fibres, familial aetiology (often there is a
positive family history) and others.4 6
ASSESSMENT
The focus of assessment is to establish
the degree of the problem (box 1) and
determine the aetiology. These will help
to decide appropriate management (see
table 1).
HISTORY
A routine paediatric history with a par-
ticular reference to the following aspects:
▸ Detailed birth history, perinatal events,
gestation, developmental progress, family
history of toe walking and neuromuscular
disorders.
▸ Specific history regarding onset of toe
walking, ability to walk with heel strike.
Whether the planti-grade foot posturing
was present before weight bearing. This
may indicate spasticity or dystonia.
▸ History of any neuropathic bladder or
bowel symptoms inappropriate for age, for
example, dribbling of urine, faecal incontin-
ence. These may indicate spinal disorders.
▸ History of language delay, intellectual dis-
ability, disordered use of language and social
skills. Toe walking has a high prevalence in
autism and/or intellectual disability.
▸ History of any sensory processing pro-
blems, for example, unusual response on
minimal exposure to any sensory stimulus
(hypersensitivity) or need for significantly
more stimulus/sensory trigger for response
(hyposensitivity).
▸ History of associated symptoms of lower
limb pain, instability and any other func-
tional problems.
▸ Assess the impact on the child and on parents.
1

Best practice
Table 1 Toe walking: aetiology, assessment and management
Aetiology
Idiopathic/habitual
Brain lesions (UMN)
Cerebral palsy (CP)
Hydrocephalus
UMN brain lesions
Spinal lesions
Spina bifida: open and closed
Tethered cord syndrome
Spinal space occupying lesion
Peripheral neuropathy
HMSN
Peroneal neuropathy
Muscle disorders
Dystrophy, for example,
Duchenne muscular dystrophy
Movement disorders
Dopa sensitive dystonia
Transient focal dystonia of
infancy
Developmental disorders
Autism spectrum disorder
Language disorders
Intellectual disability
Sensory processing disorders
Miscellaneous
Short calf tendon/muscle
Ankylosing spondylitis
Calf muscle venous
malformation
Compensatory
Local pain
DTR, deep tendon reflexes; LMN, lower motor neurone; UMN, upper motor neurone.
2 Sivaramakrishnan S, et al. Arch Dis Child Educ Pract Ed 2015;0:1–4. doi:10.1136/archdischild-2014-307852
Downloaded from http://ep.bmj.com/ on June 15, 2015 - Published by group.bmj.com
Assessment features
Starts under 2 years of age as variation of normal, usually
intermittent but then can persist.
Can walk with heel strike when asked.
May have positive family history.
Normal neurology and orthopaedic examinations except
some may have limited dorsiflexion.
Diagnosis of exclusion of other causes.
Can become persistent, especially over 3 years of age.
Can resolve spontaneously up to 5 years of age.
Any suggestive history of brain injury?
Birth history: pre, peri or post natal risk factors
Preterm with IVH or Extreme prematurity
UMN signs: spasticity/dystonia, brisk deep tendon
reflexes, clonus, extensor plantar reflex
Large OFC: any signs of hydrocephalus?
Lesions over spine/natal cleft deviation
Sacral pits
Spinal curves, especially in dysraphism
UMN±LMN signs in lower limbs
Bladder/bowel symptoms
Back pain/tenderness
Muscle wasting; ‘inverted champagne bottle’ in Charcot
Marie Tooth variant of HMSN
LMN signs: reduced reflexes; weakness of dorsiflexion;
footdrop
May have sensory loss (difficult to establish in young
children)
May have positive family history
Delayed motor milestones
Hypotonia with reduced/absent reflexes
Calf hypertrophy (DMD)
May have positive family history
May have unusual posture even prior to starting to walk.
Often have dystonic posture at rest.
May have variation: diurnal, tiredness, intercurrent illness.
May have impaired speech.
May masquerade as ‘cerebral palsy’ without risk factors
for CP or as idiopathic toe walking
Postulated to be behavioural or sensory problem but no
conclusive evidence.8
Toe walking has been reported to be associated with:
ASD, language disorders or sensory disorders in around
40% of children
Short tendon/muscles: no hypertonia in calf muscles but
restricted range of dorsiflexion. Sometimes called ‘Short
Tendocalcaneous’. Likely to be same entity or overlap
with persistent idiopathic toe walking.
Compensatory: for flexion deformity at knee or hip.
If unilateral, could be compensatory for short limb.
Management
Advise reminders of ‘heel down’. Usually will resolve.
Idiopathic toe walking persisting over 3 years or causing
functional problems or not getting heel strike at all due to
high calf tone/ contractures: review whether the diagnosis is
correct.
If no evidence of other disease:
▸ Refer for physiotherapy assessment.
▸ Consider orthoses (footwear/splints),
▸ Serial casting (good evidence)4
▸ ±Botox injections to calf muscles (insufficient evidence)5
▸ Gait analysis or Tread Mat may be helpful4 6
▸ If poor or partial response, consider orthopaedic referral
(usually after 5–7 years of age). Surgery helpful, especially
if contractures present (good evidence)4
Proceed to MRI brain and spine. If high risk factors for CP
present, then likely to be CP. Approach to management of
spasticity includes physical therapy, orthoses,
pharmacological therapy (oral, injectable, intrathecal) and
surgical approaches. Refer to National Institute for Clinical
Excellence Clinical Guidance 1457
Abnormal spinal examination and/or history of progressive
crouch gait with/without neuropathic bladder/bowel
symptoms: likely to be spinal cause, for example,
diastematomyelia. Initial investigation with MRI spine.
Further evaluation may require other neuroimaging
modalities.
Refer to paediatric neurosurgeon if MRI suggests spinal
dysraphism.
Consider investigations for neuropathy and refer to paediatric
neurologist.
Biochemical tests, neuroimaging, electrophysiology, genetic
studies and rarely nerve histology may be required
Consider muscle enzymes, electromyography and nerve
conduction studies.
Refer to paediatric neurology/neuromuscular service.
Additional genetic studies, neurometabolic tests and muscle
histology often needed.
Perform a MRI brain and spine; if normal, consider trial of
Dopa and seek paediatric neurology advice.
Could be primary dystonia or dystonic CP.
Note: Dopa sensitive dystonia can be hard to differentiate
from idiopathic toe walking or dystonic CP. If in doubt, give
a therapeutic trial of Dopa. Improvement is remarkable!
If possible obtain a sensory processing profile of the child.
Possible sensory problem: think of touch, pressure, position,
joint sense.
Think of texture/material of clothes/footwear, type of surface/
floor, pressure points.
Think of patterns on floor. Assess when/where it happens.
Touch avoidant? Prefers being bare feet? Try seamless socks.
Whose problem? Parental embarrassment or definite
functional problem, for example, won’t wear shoes?
Manage as idiopathic toe walking in ‘short tendocalcaneous’
group.
Address primary problem causing functional limb length
discrepancy in compensatory group.
 Downloaded from http://ep.bmj.com/ on June 15, 2015 - Published by group.bmj.com
Box 1 Assessment of degree of problem
▸ Can the child voluntarily walk with heel strike when
requested?
▸ Any tightness of tendo-achilles and calf muscles?
▸ Any weakness of ankle dorsiflexors?
▸ Any contractures? Any fixed limitation of
dorsiflexion?
▸ Establish range of movement with knee extended
and flexed.
▸ Is the problem at the ankle or is it compensatory for
hip and/or knee flexion deformity?
▸ Any functional effects? Pain, falls, instability, foot-
wear problems, embarrassment?
▸ Is the child actually experiencing any difficulty or is it
the parent/carer’s perception?
PHYSICAL EXAMINATION
▸ Examination of gait pattern with/without orthoses (if
any), with/without shoes, with/without socks. Can the
child walk with a heel strike? Is the child well
co-ordinated when walking and/or running on toes?
This would suggest ITW.
▸ General and musculo-skeletal examination.
▸ Developmental assessment. Look for any syndromic
associations, for example, dysmorphism.
▸ Perform detailed neurological examination including
muscle strength, tone, sensation, deep tendon reflexes and
superficial reflexes (abdominal and plantar reflex).
Consider cremasteric reflex and anal wink in spinal lesions.
▸ Spine examination: any curvature, cutaneous abnormal-
ities, swellings or open pits over the spine.
▸ Lower limb examination for pelvic asymmetry, leg length
discrepancy, muscle bulk and wasting. Particular atten-
tion should be paid to detecting contractures and tone of
hamstrings, calf muscles and range of movements at
knee and ankle. A better range of ankle movement by
flexing the knee may suggest short calf muscles. Check
Test your knowledge
Toe walking in children:
A. Over 3 years of age is usually a sign of a significant
underlying neuro-developmental problem.
B. If persistent, should be treated with botulinum toxin
injections.
C. Is commonly associated with language and/or motor
delay.
D. Persisting over 3 years of age will usually resolve
spontaneously.
Answers are at the end of the references
Sivaramakrishnan S, et al. Arch Dis Child Educ Pract Ed 2015;0:1–4. doi:10.1136/archdischild-2014-307852
Best practice
Key messages
▸ In children below 3 years of age who have no risk
factors, have normal development, normal examin-
ation, no contractures and where toe walking is a
normal variation, parents need to be reassured that it
is likely to resolve spontaneously.
▸ The vast majority of persistent toe walkers over
3 years of age are idiopathic toe walkers and have a
good chance of spontaneous resolution by 5 years of
age. Advise carers how they can help, what to look
out for and when to contact services for intervention
(see table 1). Provide ‘safety net’ advice regarding
review needs which include persistence over 5 years
of age, progressive tightening at ankle, evolving
neurological signs or any functional problems.
▸ A good consultation involves spending time to
explain the natural progression of the disorder and
the likelihood that the condition will resolve spontan-
eously. Providing written information using a parent
information leaflet is recommended.
for any deformities of ankle or foot. Many children who
toe walk can retain normal dorsiflexion (10°–20° past
neutral) but those with contractures have reduced range.
Williams et al9 developed the Toe walking Tool, a
28-item questionnaire to aid physicians in identifying the
underlying condition that leads to a toe walking gait.
MANAGEMENT
Management depends on which cause is identified
from the history and assessment (see table 1).
Competing interests None.
Provenance and peer review Commissioned; externally peer
reviewed.
REFERENCES
1 Oetgen ME, Pedan S. Idiopathic toe walking. J Am Acad
Orthop Surg 2012;20:292–300.
2 Engstrom P, Tedroff K. The prevelance and course of idiopathic
toe-walking in 5-year-old children. Pediatrics
2012;130:279–84.
3 Shulman LH, Sala DA, Chu ML, et al. Developmental
implications of idiopathic toe walking. J Pediatr
1997;130:541–6.
4 Sala DA, Shulman LH, Kennedy RF, et al. Idiopathic toe
walking: a review. Dev Med Child Neurol 1999;41:846–8.
5 Engelstrom P, Bartonek A, Tedroff K, et al. Botulinum toxin A
does not improve the results of cast treatment for idiopathic
toe walking: a randomised controlled trial. J Bone Joint Surg
Am 2013;95:400–7.
6 Caselli MA. Habitual toe walking. Podiatr Manag
2002;21:163–70.
3
 Downloaded from http://ep.bmj.com/ on June 15, 2015 - Published by group.bmj.com

Best practice
7 Spasticity in children and young people with non-progressive 9 Williams CM, Tinley P, Curtin M. The Toe Walking Tool:
brain disorders: Management of spasticity and co-existing a novel method for assessing idiopathic toe walking children.
motor disorders and their early musculoskeletal complications. Gait Posture 2010;32:508–11.
NICE CG 145 Published July 2012. http://www.nice.org.uk/
guidance/cg145/ Answers to the multiple choice questions
8 Williams CM, Tinley P, Curtin M. Idiopathic toe walking
and sensory processing dysfunction. J Foot Ankle Res
2010;3:16. (A) False; (B) False; (C) True; (D) True.

4 Sivaramakrishnan S, et al. Arch Dis Child Educ Pract Ed 2015;0:1–4. doi:10.1136/archdischild-2014-307852

 Downloaded from http://ep.bmj.com/ on June 15, 2015 - Published by group.bmj.com

Fifteen-minute consultation: A child with toe

walking
Shobha Sivaramakrishnan and Arnab Seal

Arch Dis Child Educ Pract Ed published online April 8, 2015

Updated information and services can be found at:

http://ep.bmj.com/content/early/2015/04/08/archdischild-2014-307852

These include:

References This article cites 8 articles, 3 of which you can access for free at:
http://ep.bmj.com/content/early/2015/04/08/archdischild-2014-307852
#BIBL
Email alerting Receive free email alerts when new articles cite this article. Sign up in the
service box at the top right corner of the online article.

Notes

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://group.bmj.com/subscribe/