Toe walking in children – When should a parent start worrying

Walking on the toes or the balls of the feet is noticed who are just beginning to walk. This gait is also known as toe walking. Most children outgrow it as they grow older. However, if parents observe toe walking in their children after three years, it is a cause of concern and needs medical evaluation. Toe walking in children five years and beyond is associated with neurological immaturity.

Why seek pediatric orthopedic consultation and evaluation of a child who walks on their toes?

As parents of toddlers, it is necessary to be extremely observant of their physical movements. And as they learn to walk, toe walking is considered normal.

But suppose toe walking exceeds past the toddler stage and the child stumbles frequently or displays general in-coordination, inability to bear weight on a flat foot, or has been unable to develop fine motor skills. In that case, it is a grave matter of concern that needs immediate medical attention!

Dr. Ratnav Ratan, a leading pediatric orthopedic in Delhi, shares his take on toe walking in children. He has successfully treated many children with this walking disorder and suggests early intervention and treatment is in the best interest of the child’s future.

Persistent toe walking in children needs immediate medical attention. The child could likely have autism spectrum disorder, cerebral palsy, or muscular dystrophy.

Autistic children are likely to have problems with gait or alignment. In addition, persistent toe walking increases the chances of children falling and hurting themselves frequently. Over the period, they can suffer from low self-esteem and social stigma.

Diagnosis of Toe walking

The pediatric orthopedic will ask questions relating to the physical condition of the child from birth and complications, if any, during pregnancy. 

The physical examination includes the doctor observing the child walk without the child aware of being watched apart from a physical examination. Also, the doctor will suggest the child walk with flat feet, if possible, to evaluate the smoothness of the child as required in a neurological evaluation.

Certain neurological exams are conducted to test abnormalities in the child’s nervous system about the toe walking gait. These exams are customized according to the child’s age, level of development, and extent of cooperation.

If essential, other tests such as x-rays, CT, MRI scans, and nerve and muscle tests are recommended. In addition, Electromyography (EMG) or gait analysis is done. The EMG test requires the insertion of a thin needle with an electrode in the muscle in the leg to measure the electrical activity in the affected muscle or the nerve.

Causes of Toe walking

If children with toe walking are diagnosed as normal during their medical examinations, then toe walking is considered idiopathic as no exact reason is known. It is also possible that a short Achilles tendon prevents the heel from touching the ground enabling the child to toe walk for movement.

However, if there is a reason for concern, the child should be examined for spinal cord abnormality, cerebral palsy, or muscular dystrophy. Also, children diagnosed with autism-related conditions are more likely to develop and move around in this gait.

 Muscular dystrophy is a genetic disease in which muscle fibres get damaged and weaken, causing affected children to toe walk. Children with muscular dystrophy may walk normally before their muscles fibres weaken, causing them to toe walk.

Children with cerebral palsy are likely to toe walk as there is a disorder of movement, posture, or muscle tone because of injury or abnormal development in the brain that regulates muscle function.

In the case of an autistic child, a dysfunctional vestibular system, a common problem in autism, may be responsible for toe walking. The vestibular system provides the brain with feedback regarding body motion and position.

Treatment for toe walking

Treatment for toe walking depends upon whether there is scope for the child to walk flat-footed and the age of the child. Initial treatment for a child in the age group of 2 – 5 years is usually nonsurgical.

Beginning with observation, the pediatric orthopedic doctor could suggest serial casting to break the toe walking habit for several weeks. Serial casting also encourages progressive stretching and lengthening of the muscle and tendons in the calf, which promotes a normal walking pattern.  Bracing using an ankle-foot orthosis (AFO) is yet another alternative used to stretch and lengthen the muscles and the tendons. The ankle-foot orthosis is a plastic brace designed to hold the foot at a 90 degrees angle. This procedure is known as bracing, and the child may have to wear the orthosis for a couple of months for better outcomes.

Botox therapy is suitable for children with neurologic abnormalities. An injection of botulinum A toxin (Botox®) weakens the calf muscles temporarily and helps to easily stretch the muscles when the pediatric doctor is casting or bracing the child.

Treating toe walking in children with autism is possible through therapeutic vestibular stimulation (e.g., being swung on a glider swing) and physical therapy if suitable.

Surgical Treatment for toe walking in children

The surgical procedure recommended is to lengthen the Achilles tendons to improve the range of motion and enable better functioning of the foot and ankle. This procedure is suggested to treat children above five years of age as their calf muscles and Achilles tendons could be very tight and unsuitable for flat-footed walking.

 The pediatric orthopedic doctor will decide which part of the tendon to lengthen for flat positioning of the foot at the ankle and whether the knee will be bent. Parents need to have faith in the doctor to suggest the best lengthening technique.

The Achilles lengthening procedure is an outpatient procedure performed under general anesthesia. In addition, the legs will be placed in short-leg walking casts, which must be worn for 4 to 6 weeks.

Post-surgery care and recovery

After both surgical and nonsurgical treatment, physical therapy is a must as it helps the patient learn how to walk flat-footed correctly. In the case of a surgically treated child, physical therapy begins after the walking casts are removed. 

Outcome

 The outcome of a child treating for toe walking is usually good. There is considerable improvement in the walking pattern, and the child can take part in sports and normal activities.