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Abstract

Idiopathic toe-walking is a diagnosis of exclusion when a child presents with bilateral toe-to-toe gait. Although toe-walking is considered part of the normal gait spectrum in development, it is abnormal when persisting past the age of two. 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. However, it may be difficult to differentiate mild forms of cerebral palsy, specifically mild spastic diplegia, and idiopathic toe-walking. The treatment options for idiopathic toe-walking include observation, conservative methods and surgical methods. Most children can be treated in the primary care setting with either observation or conservative treatment. Patients with severe contracture of the Achilles tendon, or persistent toe-walking, may need surgical intervention. The prognosis of idiopathic toe-walking is favorable with both conservative and surgical treatment allowing children to attain normal function and range of plantarflexion. The following article provides an overview of the background information, differential diagnosis and treatment options for idiopathic toe-walking.
53
Journal
February 2008
Introduction
Toe-walking is a physical sign that is considered part of the
normal spectrum of gait development in children. However,
a child with a toe-to-toe gait pattern that persists at 2 years
of age is considered abnormal.
1
The possible causes of
persistent toe-walking include cerebral palsy, congenital
contracture of the Achilles tendon, paralytic muscular
disorders such as Duchenne Muscular Dystrophy, and
idiopathic toe-walking.
1
Toe-walking may also be associated
with other diagnoses such as spinal tumors or dysraphism,
autism or other development disorders, and other
myopathic or neuropathic disorders.
2
The natural history of
prolonged idiopathic toe-walking is inconclusive in the
long term. There are no long-term natural history studies to
date. Untreated, persistent toe-walking may place children
at increased risk for falling or developing limitations in
ankle mobility and structural abnormalities, such as persist-
ent outward tibial torsion.
1
One study, however, found that
in the absence of treatment, mild progression of heel-cord
contractures was as frequent as mild regression.
3
The
authors concluded that prolonged toe-walking does not
result in significant functional disturbance, foot deformities
Idiopathic Toe-Walking
By Aaron Babb, MSII; Walter O. Carlson, MD
Abstract:
Idiopathic toe-walking is a diagnosis of exclusion when a child
presents with bilateral toe-to-toe gait. Although toe-walking is
considered part of the normal gait spectrum in development, it is
abnormal when persisting past the age of two. 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.
However, it may be difficult to differentiate mild forms of cerebral
palsy, specifically mild spastic diplegia, and idiopathic toe-
walking. The treatment options for idiopathic toe-walking
include observation, conservative methods and surgical methods.
Most children can be treated in the primary care setting with
either observation or conservative treatment. Patients with severe
contracture of the Achilles tendon, or persistent toe-walking,
may need surgical intervention. The prognosis of idiopathic
toe-walking is favorable with both conservative and surgical
treatment allowing children to attain normal function and range
of plantarflexion. The following article provides an overview of
the background information, differential diagnosis and treatment
options for idiopathic toe-walking.
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February 2008
Journal
or pain.
3
Another study found that idiopathic toe-walking
occurs in conjunction with learning problems, and the
authors suggest that idiopathic toe-walking should be
viewed as a marker for developmental disorders.
4
The diagnosis of idiopathic toe-walking is one of exclusion.
Idiopathic toe-walking is seen in normal children with a
normal neurological examination and birth history. The
etiology is not known for idiopathic toe-walking, although
some authors have suggested the cause to be congenitally
short tendo calcaneus.
1
There also appears to be a genetic
factor involved, as it has been reported that 30 percent of
children with idiopathic toe-walking have a positive family
history with autosomal dominance and variable expression
being suggested.
3,5
The diagnosis of idiopathic toe-walking is
most often made through the history and physical examina-
tion, but may be especially difficult when distinguishing it
from mild forms of cerebral palsy such as mild spastic diplegia.
Diagnosis
Idiopathic toe-walking is also called habitual toe-walking,
idiosyncratic toe-walking or forefoot walking.
3
The patient
presents as a toddler when walking develops. The child
appears normal and begins to walk at a normal age, which
is up to 18 months.
6
Balance and coordination are normal
for age development and deep tendon reflexes are normal.
The child may have restriction in passive dorsiflexion
because of tightness, or contracture, in the plantar flexors of
the ankle. The patient must have symmetrical involvement;
any asymmetry causes elimination of an idiopathic toe-
walking diagnosis.
The eventual diagnosis of idiopathic toe-walking must be
preceded by the exclusion of other possible etiologies. The
history and physical examination can be used to rule out
the majority of alternative diagnoses. Toe-walking that
begins after a mature heel-to-toe gait pattern has been
established may signify muscular dystrophy, diastemato-
myelia, peroneal muscular atrophy or spinal cord tumor.
3
Variations of cerebral palsy, especially spastic diplegia, are
the most common diagnoses to be considered. Moderate or
severe diplegia is differentiated through the history and
physical examination. Children with cerebral palsy begin
walking at a later age and have hyperactive deep tendon
reflexes.
1
Children able to put their feet flat on request or
when concentrating on their gait are more likely to have
idiopathic toe-walking than spastic diplegia.
1
Also, children
with idiopathic toe-walking may initially cruise along
furniture high on their toes and then may lower their heels
to the ground when standing.
1
Mild spastic diplegia is often difficult to differentiate from
idiopathic toe-walking using only the history and physical
examination. This differentiation is important because of
the very different long-term prognostic implications.
7
Although prematurity is a risk factor for cerebral palsy, it
cannot be used to differentiate mild diplegia from idiopath-
ic toe-walking.
8
A retrospective study found no difference
in duration of gestation or length of postnatal hospital stay
between mild diplegia and idiopathic toe-walking patients.
8
Formal gait analysis and electromyographic (EMG) testing
have been studied in the literature to differentiate idiopathic
toe-walking and mild spastic diplegia, but studies have been
mostly inconclusive. One study noted that both causes of
toe-walking have premature firing of the gastrocnemius in
the swing phase of gait.
8
Also, initial contact during gait
fails to differentiate between mild spastic diplegia and
idiopathic toe-walking because both groups are
plantarflexed and use a forefoot initial strike.
8
Differences
have been found to exist in gait studies between children
with spastic diplegia and idiopathic toe-walking. One
difference seen in gait analysis is that patients with spastic
diplegia can not obtain full knee extension in late swing
and early stance unlike children with idiopathic toe-
walking.
8
Additionally, idiopathic toe-walkers attain
maximal knee extension at ground contact, similar to
normal heel-to-toe walkers, but in the diplegic group,
maximal knee extension occurs at mid to late stance.
7
A
difference is also seen in ankle kinematics as patients with
spastic diplegia have ankle excursion toward dorsiflexion
throughout the swing phase.
7
Idiopathic toe-walkers
demonstrate a pattern of initial excursion toward dorsiflex-
ion in mid-swing, followed by active plantarflexion,
prepositioning the foot to land in equinus.
7
Normal
children asked to toe-walk have the same kinematic pattern
as children with idiopathic toe-walking.
7
Another viable test used to differentiate the two groups is
EMG testing during voluntary quadriceps contraction. Policy
et al. found patients with mild diplegia to have increased
coactivation of the gastrocnemius during resisted knee exten-
sion and quad set compared with idiopathic toe-walking
patients.
8
The authors concluded that when attempting to
differentiate an idiopathic toe-walker from a patient with
mild diplegia, testing for gastrocnemius coactivation during
Feb08 Issue v4 2/6/08 4:02 PM Page 15
56
resisted knee extension and quad set is beneficial.
Another study described vestibular dysfunction in mentally
retarded children who toe-walk and found that 13 of 17
temporarily stopped toe-walking immediately after vestibu-
lar stimulation.
3
The authors theorized that the purpose of
toe-walking may be to increase sensory stimulation.
3
Treatment
The treatment options for children with idiopathic
toe-walking include observation and nonoperative and
operative management. Conservative treatment of
idiopathic toe-walking includes observation, stretching,
serial casting, splinting, orthotics and possibly the use of
botulinum toxin in the future.
9
A toe-to-toe gait pattern can be part of the natural progres-
sion of the normal heel-to-toe gait. A child demonstrating
toe-walking before the age of two should be observed at
six-month intervals for progressive Achilles tendon
contractures. Treatment should be considered if the child
does not spontaneously resolve the toe-walking pattern by
three or continues to have tightness of the plantar flexors.
Children with minimal Achilles tendon contractures can
be monitored for spontaneous resolution. Stricker and
Angulo concluded that the majority of untreated children
with mild heel cord contractures remain essentially the
same over several years.
3
Stretching methods can also be incorporated while observing
the child. Manual passive dorsiflexion by a parent or
therapist is often ineffective because of the strength of the
plantar flexors seen in children.
6
For this reason, techniques
for stretching that utilize the child’s body weight are often
recommended. A runner’s type stretch, or having the child
stand with the balls of their feet on a board or step and then
dropping the heel down, are two such examples.
The recommended treatment by many authors for children
with mild Achilles tendon contractures is serial casting for
six to eight weeks to improve ankle dorsiflexion.
3
Serial
casting involves the application of a series of below-knee
casts with the foot initially casted in a neutral position.
2
Casts are changed every one to two weeks to obtain progres-
sively greater range of dorsiflexion through lengthening of
the Achilles tendon.
6
The majority of studies illustrate improvement with
occasional toe-walking after cast placement, but long-term
outcome studies are lacking.
3
Some authors depict serial cast-
ing as a labor-intensive method that obtains varying results
and should be carefully considered for appropriate patients.
3
An articulated molded ankle foot orthosis (MAFO) is an
additional conservative treatment option. This specific
orthosis fits in a regular shoe and allows near normal
dorsiflexion while preventing plantar flexion. The MAFO
stretches the Achilles tendon with every step and is worn
during all waking hours for at least six months.
6
The
utilization of this orthosis helps to re-establish a normal gait
pattern.
Botulinum toxin A treatment is used to paralyze the
gastrocnemius muscle to allow effective stretching and
retraining of the muscle for normal gait.
8
This treatment
method has been used successfully in the management of
children with cerebral palsy; however, its use is currently
unproven in the treatment of idiopathic toe-walking.
8
Currently, there is a randomized control trial being
conducted using botulinum toxin A injections in the gas-
trocnemius muscle of children with idiopathic toe-walking.
11
Conservative methods are effective for the majority of
children with idiopathic toe-walking, and conservative
methods can be managed in the primary care setting. If
these methods fail, however, it is appropriate to refer the
child to a pediatric orthopedist for further evaluation.
Surgical intervention for idiopathic toe-walking consists of
Achilles tendon lengthening. This method is reserved for
patients who have severe contracture of the Achilles
tendon or conservative treatment has failed over a period of
12 months.
6
The procedure involves either an open or
percutaneous technique with a postoperative period of four
to six weeks in a below-knee cast.
1
Patients are able to
ambulate as tolerated after removal of the casts, and most
children will be forced to walk flat-footed for a period of
time while the gastrocnemius and soleus muscles regain
strength.
6
Hemo et al. concluded that patients treated
surgically for idiopathic toe-walking do not have detectable
decreases in plantarflexion power.
5
Parental satisfaction is
high after surgical intervention for idiopathic toe-walking
and has been advocated by many authors.
2
The chief
complication occurring in Achilles tendon lengthening is
recurrence of toe-walking, although this is rare. Finally,
Journal
Feb08 Issue v4 2/6/08 4:02 PM Page 16
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February 2008
Journal
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patients treated with conservative or surgical treatment
may continue to walk on their toes unobserved into
adulthood.
2
Conclusion
Toe-walking is considered part of the normal spectrum of
heel-to-toe gait development of children. A child continuing
with a toe-to-toe gait pattern that persists past the age of
two is considered abnormal and should be thoroughly
evaluated. Idiopathic toe-walking is typically diagnosed by
excluding other causes through the history and physical
examination. However, differentiating mild forms of
cerebral palsy and idiopathic toe-walking may demand
additional testing. The treatment options include observa-
tion, conservative methods and surgical methods, which
should be tailored to the severity of the child’s Achilles
contracture. The majority of patients will resolve either on
their own or with conservative treatment. Yet, if toe-walking
persists, surgical treatment options are successful in both
clinical prognosis and parental satisfaction.
1. Kogan M, Smith J. Simplified approach to idiopathic toe-walking. J Pediatr
Orthop. 2001;21:790-791.
2. Stott SN, et al. Treatment for idiopathic toe-walking: results at skeletal
maturity. J Pediatr Orthop. 2004;24:63-69.
3. Stricker S, Angulo J. Idiopathic toe walking: a comparison of treatment
methods. J Pediatr Orthop. 1998;18(3):289-293.
4. Shulman LH, et al. Development implications of idiopathic toe walking.
Journal of Pediatrics. 1997;130(4):541-546.
5. Hemo Y, et al. Outcome of patients after achilles tendon lengthening for
treatment of idiopathic toe walking. J Pediatr Orthop. 2006;26:336-340.
6. Schwentker EP. Toe walking. Available from: emedicine.com (Accessed July
26, 2007).
7. Kelly IP, et al. The kinematic patterns of toe-walkers. J Pediatr Orthop.
1997;17(4):478-480.
8. Policy JF, et al. Electromyographic test to differentiate mild diplegic cerebral
palsy and idiopathic toe-walking. J Pediatr Orthop. 2001;21:784-789.
9. McMulkin ML, et al. Comprehensive outcomes of surgically treated
idiopathic toe-walkers. J Pediatr Orthop. 2006;26:606-611.
10. Davids JR, et al. Voluntary (normal) versus obligatory (cerebral palsy) toe-
walking in children: a kinematic, kinetic, and electromyographic analysis.
J Pediatr Orthop. 1999; 19(4):461-469.
11. www.clinicaltrials.gov. (Accessed December 2007).
REFERENCES
About the Author:
Aaron Babb, MSII, Georgetown University, Washington, DC.
Walter O. Carlson, MD, Orthopedic Surgeon, Orthopedic Institute, Sioux Falls,
SD; Clinical Associate Professor, Department of Surgery, Sanford School of
Medicine of The University of South Dakota.
Feb08 Issue v4 2/6/08 4:02 PM Page 17
... In the study by Bernhard et al, 17 the main objectives of physical therapy for children with ITW, are to obtain stability of the trunk muscles, and to 17 Pomarino et al (2011) 18 Pomarino et al (2011) 19 Pomarino et al (2011) 20 Van Kujik et al (2014) 21 Fox et al (2006) 22 Pomarino et al (2011) 23 Pomarino and Pomarino (2010) 24 Pomarino et al (2010) 15 Gámez-Iruela et al (2015) 25 Hemo et al (2006) 11 Pomarino et al (2011) 26 Pomarino et al (2009) 27 Pomarino et al (2012) 16 Williams et al (2014) 28 Jahn et al (2009) 29 Pomarino et al (2010) 30 Pomarino et al (2009) 31 Babb and Carlson (2008) 32 Williams et al (2014) 33 Pomarino et al (2010) 34 Külh and Pomarino (2008) 35 Brunt et al (2004) 36 Pomarino et al (2010) 15 Pomarino, et al (2007) 37 Zimbler (2007) 38 Pomarino and Bernhard (2006) 39 Pomarino (2004) 40 Engström et al (2010) 10 Bernhard et al (2006) 41 Clark et al (2010) 13 Hirsch and Wagner (2004) 42 Lundequam and Buck Willis (2009) 43 Williams et al (2013) 9 McEwen-Hill and Weber (2009) 44 Stott et al (2004) 14 Stock and Zörnig (2010) 45 Engström et al (2013) 8 by guest on September 21, 2016 fas.sagepub.com Downloaded from elongate the Achilles tendon; the exercises or therapy have to be done regularly. ...
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The idiopathic toe walking (ITW) gait pattern is characterized in children for walking since the beginning on their first steps on the forefoot; however, these children are able to support their whole foot on the ground. ITW can only be diagnosed in the absence of any orthopaedic or neurological condition known to cause tiptoe walking. The aim of this article is to review other references and provide an outline of the different treatment options, including the 3-step-pyramid insole treatment concept for children with ITW. Methods: Fifty-four articles in English, German, and Spanish were reviewed. There were comparative, retrospective or case studies, classifications or literature reviews and they were divided according with these categories. All the literature reviewed was published between 2000 and 2015. Results: There are some studies that proved the 3-step pyramid insole treatment concept as an effective option compared with other therapeutic modalities such as physical therapy, casting, botolinum toxin type A (BTX), and surgery. Conclusion: There is a wide spectrum regarding the therapeutic options for children with ITW, from physical therapy to surgery options. However, any of these treatment modalities have been reported to be fully successful for the whole toe walking population. Some procedures seem to have achieved faster results or seem to have longer lasting effects. Therefore, further research on the causes of ITW is recommended. Levels of evidence: Therapeutic, Level II: Systematic review, prospective, comparative.
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Children who toe-walk can pose a diagnostic problem. The differential diagnosis includes mild spastic diplegia and idiopathic toe-walking. Clinical differentiation between these two patient groups can be particularly difficult, and there are no objective diagnostic tests to assist the clinician. We assessed 50 children who toe-walk to define the kinematic patterns of lower-limb joint motion in the sagittal plane. There were 23 children with mild spastic diplegia. 22 idiopathic toe-walkers, and five normal children who were asked to toe-walk. We found characteristic patterns of knee and ankle motion that differentiated spastic diplegia from idiopathic toe-walking. Normal children asked to toe-walk had the same pattern as the idiopathic group. Gait analysis is a diagnostic tool that enables the clinician objectively to differentiate mild spastic diplegia from idiopathic toe-walking.
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Eighty children with idiopathic toe walking (ITW) were examined 2-8 years (average, 34 months) after initial presentation to compare outcomes [passive ankle dorsiflexion (DF) and parental satisfaction] after three treatment modalities: observation, cast/brace treatment, or surgical triceps surae lengthening. Overall, 32% had a family history of ITW, 28% were born prematurely, and 16% had psychomotor delay. Forty-eight untreated patients showed little change in passive ankle DF at final follow-up, and only 25% of parents were satisfied with the child's gait. Compared with untreated children, casting/bracing appeared to offer no significant improvement in ankle DF or parental satisfaction. Surgical treatment was performed in 15 children with more severe equinus contractures. Triceps surae lengthening resulted in significantly improved ankle DF and 67% parental satisfaction (p < 0.05). Toe walking may persist after all standard treatment methods, even in the absence of significant Achilles contracture.
Article
Surgical management of toe-walking gait in children with cerebral palsy currently favors simultaneous, multilevel soft-tissue and bony interventions. Formulation of such a surgical plan is based on our ability to determine which of the gait deviations present are primary and which are secondary or compensatory. To evaluate this issue further, 32 normal children, walking normally and voluntarily toe-walking, were compared to 15 children with cerebral palsy walking in an obligatory toe-walking gait pattern. Computer-based analysis of gait was performed for each child, including time-distance, kinematic, kinetic, and electromyographic analyses. Significant deviations common to both normal and cerebral palsy toe-walking groups were determined to be due, at least in part, to the biomechanical constraints associated with a toe-walking gait pattern. Deviations unique to the cerebral palsy group were thought to represent primary gait deviations related to the underlying injury to the central nervous system. This study identifies the need to develop more sophisticated techniques of data collection and analysis and supports the inclusion of more varied and demanding functional activities for distinguishing between primary and secondary gait deviations in children with cerebral palsy.
Article
Controversy exists as to the treatment of idiopathic toe-walking (ITW). Since 1993, the authors have managed children with ITW using an outpatient percutaneous lengthening of the Achilles tendon, followed by placement of below-knee walking casts for 4 weeks. The authors reviewed 15 children who were treated for ITW with percutaneous Achilles tendon lengthening between 1993 and 1999. Ten of the 15 patients could be contacted for a follow-up survey. None of the parents stated that their child's toe-walking had recurred. There were no painful scars. All of the children were able to keep up with other children and did not notice any calf weakness. Two children had occasional Achilles tendinitis, which was relieved with antiinflammatory medications. All parents were satisfied with their child's outcome. The authors believe that percutaneous tendo-Achilles lengthening in ITW greatly simplifies the management of ITW.
Article
Thirteen skeletally mature subjects who had been treated as children for idiopathic toe-walking underwent gait analysis and calf muscle strength testing at an average of 10.8 years from the last intervention. Six had had serial casting only; seven had had either a percutaneous tendo Achilles lengthening or a Baker's gastroc-soleus lengthening. Sagittal plane kinematics at the ankle was altered in 12 of the 13 subjects, but the changes were detectable visually in only 3 subjects. One subject had increased ankle plantarflexion at initial contact, but the other 12 subjects had a normal first rocker. Peak ankle dorsiflexion in stance averaged only 9 degrees, and 11 of the subjects had a peak ankle dorsiflexion in stance greater than 2 standard deviations below normative values. Ankle dorsiflexion was also restricted on passive measures, but there was no correlation between ankle dorsiflexion non-weight-bearing and in gait. Inversion of second rocker was seen in two subjects with peak ankle dorsiflexion in stance occurring before 25% of the gait cycle. Power generation by the calf during a single heel-rise test was variable between subjects but within normative values compared with controls. The authors conclude that most subjects showed persistent changes in ankle kinematics and kinetics despite treatment but that this was not detectable visually in most subjects.