Idiopathic Toe Walking

Idiopathic Toe Walking (ITW) is a condition where children walk on their toes (forefoot contact) without any identifiable neurological or orthopedic cause.

Natural History:

• Early Walkers: New walkers often toe-walk intermittently for the first 3-6 months. This is normal.
• Resolution: Most ITW resolves spontaneously.
• Persistence: If it persists beyond age 3, it is considered pathological/habitual.
• Sequelae: Long-term toe walking leads to adaptive shortening of the Achilles tendon (equinus contracture), widening of the forefoot (splay foot), and rarely traumatic symptoms in adolescence.

Associations:

• Speech Delay/Autism: High prevalence of toe walking in children with ASD (Sensory processing).
• ADHD: Also associated.

Etiology Theories

Several theories attempt to explain idiopathic toe walking:

Neurological Hypothesis:

• Incomplete maturation of central pattern generators
• Abnormal supraspinal control of gait
• Vestibular dysfunction affecting postural control
• Sensory processing abnormalities

Musculoskeletal Hypothesis:

• Primary shortening of gastrocnemius-soleus complex
• Altered muscle fiber composition (increased Type I fibers)
• Developmental variation in tendon length
• Habitual pattern leading to adaptive shortening

Genetic Factors:

• Strong familial clustering (30-70% have positive family history)
• Autosomal dominant inheritance pattern suggested
• May represent a phenotypic spectrum with variable penetrance

The Gastroc-Soleus Complex:

• Gastrocnemius: Crosses the knee and ankle. Tightness is tested with the knee extended.
• Soleus: Crosses only the ankle. Tightness is tested with the knee flexed.
• Silfverskiold Test: Essential to differentiate gastroc vs soleus tightness.
  • Gastroc Tightness: Ankle dorsiflexion improves when knee is flexed. (Most common in ITW).
  • Soleus/Combined: Ankle dorsiflexion remains limited even when knee is flexed.

Biomechanics of Toe Walking:

• Initial Contact: Forefoot strike instead of heel strike.
• Mid-stance: "Vaulting" over the stiff ankle.
• Push-off: Often powerful, "bouncing" gait.
• Compensations: Anterior pelvic tilt, lumbar lordosis (sway back) to shift center of gravity forward.

Muscle Fibre Types:

• Histological studies of calf muscle in ITW show a specific pattern: Increased Type I (slow twitch) fibers, suggesting a chronic adaptation to sustained activity rather than a primary myopathy.

History:

• Birth: Prematurity? NICU stay? (CP).
• Milestones: Did they walk late? (Duchenne/Myopathy).
• Family Hx: Do dad/mum walk on toes?
• Pattern: Intermittent or Constant? Worse when tired?
• Pain: Is there pain? (Pain usually points to a tarsal coalition or infection/tumor, not ITW).

Physical Exam:

1. Gait: Observe walking and running. Ask them to "walk like a penguin" (heels only) and "walk like a giant" (toes).
2. Neurological:
   • Reflexes (Patella/Achilles).
   • Clonus (Rapid rhythmic beating).
   • Tone (Catch?).
   • Gowers Sign (Ask child to stand up from floor - do they walk hands up thighs?).
3. Orthopedic:
   • Silfverskiold Test: Check DF with knee straight vs bent.
   • Popliteal Angle: Check hamstring tightness (often associated).
   • Spine: Check for hairy patch/dimple (Spina bifida occulta).

Labs:

• CK (Creatine Kinase): Mandatory in all males with idiopathic toe walking to rule out Duchenne Muscular Dystrophy.
• Genetic Testing: If suspicious features.

Imaging:

• X-rays (Lateral Stand):
  • Look for "talar beaking" (chronic impingement).
  • Look for Tarsal Coalition (C-sign).
• Spine MRI:
  • Indication: If any neurological signs (asymmetry, atrophy, reflex change, bladder issues).
  • Rule out: Tethered cord, syrinx, diastematomyelia.

Gait Analysis:

• Shows "double bump" absent pattern.
• Premature calf activation.
• Used in research, rarely essential for straightforward clinical cases.

Management of Complications

Recurrence Management:

• Early detection through regular follow-up is essential
• Mild recurrence: Resume stretching program, consider night splints
• Moderate recurrence: Repeat serial casting course
• Severe recurrence with fixed contracture: Surgical revision may be required
• Consider underlying cause if multiple recurrences (tethered cord, evolving CP)

Overcorrection / Calcaneal Gait:

• Prevention is key - never lengthen beyond neutral dorsiflexion
• If occurs: AFO to support ankle in slight plantarflexion
• Physiotherapy for gastrocnemius strengthening
• Very difficult to reverse surgically
• May require tendon transfer procedures in severe cases

Weakness After Surgery:

• Expected after TAL (affects push-off power)
• Less common after Strayer (preserves soleus)
• Progressive strengthening protocol essential
• Most patients compensate over 6-12 months
• May limit high-level athletic performance

Protocol for Strayer:

• Weeks 0-4: Walking Cast in Neutral Dorsiflexion (or slight Plantarflexion if tension high).
• Weeks 4-6: Night Splints (AFO). Begin active stretching.
• Weeks 6+: Return to sports.

Note on Night Splints:

• Evidence suggests night splinting is crucial to prevent recurrence in the first 12 months, as the child grows (bone grows faster than muscle).

Detailed Rehabilitation Protocol

Phase 1: Immobilization (Weeks 0-4)

• Below-knee walking cast or CAM boot
• Weight bearing as tolerated with crutches initially
• Gentle ankle pumps when cast removed for review
• Ice and elevation for swelling management

Phase 2: Early Mobilization (Weeks 4-8)

• Transition from cast to AFO or supportive footwear
• Begin active dorsiflexion exercises
• Proprioceptive training on stable surfaces
• Gradual increase in walking distance
• Pool therapy if available (reduced weight bearing)

Phase 3: Strengthening (Weeks 8-12)

• Progressive resistance exercises for tibialis anterior
• Eccentric calf lowering exercises (controlled)
• Single leg balance exercises
• Step ups and downs
• Stationary cycling

Phase 4: Return to Activity (Weeks 12+)

• Sport-specific training progression
• Running progression (walk-jog program)
• Jumping and hopping activities
• Full return to sport when power normalized

• Natural History: 20% of untreated mild toe walkers will spontaneously resolve.
• Recurrence: ITW is notorious for recurrence, especially during growth spurts.
• Adult Sequelae: Few studies on untreated ITW in adults. Most function well but may have forefoot pathology (metatarsalgia) or calf tightness.

Factors Affecting Prognosis

Positive Prognostic Indicators:

• Younger age at presentation (less than 5 years)
• Mild contracture (can achieve neutral passive DF)
• No underlying neurological or developmental condition
• Consistent compliance with stretching/splinting program
• Family history only (suggests benign hereditary variant)

Negative Prognostic Indicators:

• Older age at presentation (greater than 7 years)
• Severe fixed contracture (greater than 15 degrees equinus)
• Associated autism spectrum disorder or sensory processing issues
• Multiple failed casting attempts
• Non-compliance with post-treatment splinting

Long-Term Follow-Up Recommendations

Post-Casting Follow-Up:

• Review at 6 weeks, 3 months, 6 months, 12 months
• Measure dorsiflexion at each visit
• Continue night splints for minimum 6-12 months
• Re-cast if recurrence detected early

Post-Surgical Follow-Up:

• 2 weeks: Wound check
• 6 weeks: Remove immobilization, start physio
• 3 months: Assess gait, measure strength
• 6 months: Sport clearance if appropriate
• Annual review until skeletal maturity

• Referral Pathways: Often referred to Paediatricians or Community PT first.
• Waiting Lists: Long waits for public "gait clinics".
• NDIS: Many of these children (especially if ASD) are under NDIS. Funding can be used for Physio and Serial Casting.
• Cultural: "Walking on tip-toes" is often dismissed by GPs as "they will grow out of it", leading to late presentation with fixed contractures.

Australian Healthcare Considerations

Public Hospital Pathway:

• GP referral to paediatric orthopaedic clinic
• Average wait time 6-12 months in metropolitan areas
• Gait analysis services available at major children's hospitals (RCH Melbourne, CHW Sydney, QCH Brisbane)
• Serial casting typically performed as outpatient procedure

Private Practice Pathway:

• Shorter wait times (2-4 weeks typically)
• Out-of-pocket costs for consultations and casting
• Surgery performed in private day surgery facilities
• Private health insurance covers inpatient procedures

Multidisciplinary Resources:

• Cerebral Palsy Alliance provides physiotherapy services
• NDIS funds allied health for eligible children
• School-based physiotherapy programs available
• Telehealth consultations increasingly available for regional families

Evidence-Based Guidelines:

• Australian Physiotherapy Association guidelines recommend observation under 3 years
• RACS position: Surgery reserved for failed conservative management
• Botox use varies by centre (some use routinely, others rarely)

Why do they do it? In children with ASD or Sensory Processing Disorder, toe walking is theorized to be:

• Seekers: Seeking intense proprioceptive input through the calf muscles.
• Avoiders: Avoiding tactile sensation of the floor on their heels/soles.
• Vestibular: Altering head position in space. Implication: Mechanical treatment alone (casting/surgery) may fail if the sensory drive remains. Occupational Therapy is key.

2. Describe a positive Gowers sign.

Q: Will he grow out of it? A: If he is under 3, possibly. If he is 7 and has tight heels, no. He needs help (stretches or casting).

Q: Is surgery dangerous? A: It is low risk, but "over-lengthening" is a disaster where the child walks flat but has no power to run or jump. We are very conservative to avoid this.

Q: Why do we have to cast? Can't we just stretch? A: Once the tendon is physically short (contracture), manual stretching is like trying to stretch a leather belt. It doesn't work well. Casting provides a "low load, long duration" stretch that actually remodels the tissue.

Q: Does Botox cure it? A: No. Botox just relaxes the muscle temporarily. We use it to make the casting easier and more effective, but the casting does the work.

Q: What about AFOs (ankle braces)? A: AFOs can help maintain correction after casting or surgery, and are useful as night splints to prevent recurrence. They don't actively stretch the tendon but prevent it from shortening again. Solid AFOs are best for contracture prevention.

Q: Can toe walking cause back pain? A: Chronic toe walking can cause compensatory lumbar lordosis (swayback) to shift the centre of gravity forward. This may contribute to back pain in some cases, though studies haven't shown a strong long-term association.

Q: My child was diagnosed with autism. Will the toe walking treatment still work? A: Treatment outcomes are somewhat less predictable in children with autism spectrum disorder. The mechanical treatment (casting/surgery) can still work for the contracture, but the sensory-seeking behaviour may persist. Occupational therapy addressing sensory processing is an important part of management.

Patient: 9-year-old male. History: Tioe walker since age 2. "Physio didn't work". Exam:

• Fixed equinus: -20 degrees dorsiflexion with knee straight. -10 degrees with knee bent.
• Neuro: Normal. CK: Normal.
• Gait: Bouncing, early heel rise.

Management:

• Attempted Serial Casting x 6 weeks. Improved to neutral, but recurred within 3 months.
• Surgery: Zone 1 Gastrocnemius Recession (Strayer).
• Intra-op: 2.5cm gap obtained in muscle belly. Dorsiflexion improved to +15 degrees.
• Post-op: Walking boot 4 weeks. Night splints 6 months.
• Outcome: Walks flat. Plays soccer. No recurrence at 2 years.

Key Learning Points from Case

1. Serial casting should be attempted first even in older children with fixed contractures
2. Zone 1 (Strayer) is preferred when gastrocnemius is the primary problem (positive Silfverskiold)
3. Post-operative splinting is crucial - minimum 6 months to prevent recurrence
4. Complete neurological workup (CK, neuro exam) must precede any surgical intervention
5. Realistic expectations - improvement takes time and compliance is essential

Additional Case Scenarios

Case 2: The Toddler

• 2.5-year-old female, intermittent toe walking noticed by parents
• Can stand flat on command, no contracture
• Normal neurological examination
• Management: Reassurance, observation, reassess at age 3-4 if persists

Case 3: The Duchenne Suspect

• 4-year-old male with toe walking, difficulty climbing stairs
• Positive Gowers sign, enlarged calves
• CK level: 15,000 U/L (normal less than 200)
• Management: Urgent referral to paediatric neurologist, genetic testing, NOT orthopaedic surgery