toe walking

Idiopathic toe walking is always bilateral and has no orthopedic or neurological cause. It is diagnosed after if it continues past the age of three.{{cite journal |last1=Stricker |first1=S |title=Idiopathic toe walking: a comparison of treatment methods |journal=Pediatr Orthoped |date=1998 |volume=18 |issue=3 |pages=289–93 |doi=10.1097/00004694-199805000-00003|pmid=9600550 }} In this condition, children are able to voluntarily walk with the typical heel-toe pattern, but prefer to walk on their tip toes. In order for it to be considered idiopathic, the child's medical history should be clear of any neurological, orthopedic, or neuro-psychiatric conditions including other gait abnormalities.{{cite journal |last1=Williams |first1=C |last2=Tinley|first2=P|last3=Curtin|first3=M|title=The Toe Walking Tool: a novel method for assessing idiopathic toe walking children |journal=Gait & Posture |date=2010 |volume=32 |issue=4 |pages=508–11 |doi=10.1016/j.gaitpost.2010.07.011 |pmid=20692159}}{{cite journal|last1=Kuijk|first1=A|last2=Kosters|first2=R|last3=Vugts|first3=M|last4=Geurts|first4=A|title=Treatment for idiopathic toe walking: A systematic review of the literature|journal=Journal of Rehabilitation Medicine|date=2014|volume=46|issue=10|pages=945–957|doi=10.2340/16501977-1881|pmid=25223807|doi-access=free}} It is thought to be related to sensory processing challenges.{{cite journal |last1=Fanchiang |first1=H |last2=Geil |first2=M |last3=Wu |first3=J |last4=Ajisafe |first4=T |title=The Effects of Walking Surface on the Gait Pattern of Children With Idiopathic Toe Walking |journal=Journal of Child Neurology|date=2016 |volume=31 |issue=7 |pages=858–863 |doi=10.1177/0883073815624760|pmid=26733505 |s2cid=5526538 |doi-access=free }}{{cite journal |last1=Williams |first1=C |last2=Tinley |first2=P |last3=Curtin |first3=M |last4=Wakefield |first4=S |last5=Nielson |first5=S |title=Is Idiopathic Toe Walking Really Idiopathic? The Motor Skills and Sensory Processing Abilities Associated With Idiopathic Toe Walking Gait |journal=Journal of Child Neurology |date=2014 |volume=29 |issue=1 |pages=71–78 |doi=10.1177/0883073812470001|pmid=23349518 |s2cid=5696959 }}

Two classifications of idiopathic toe walking have been established. The Alvarez's classification identifies the severity of the toe walking based upon kinematics and ankle rockers.{{cite journal|last1=Alvarez|first1=Christine|last2=De Vera|first2=Mary|last3=Beauchamp|first3=Richard|last4=Ward|first4=Richard|last5=Black|first5=Alac|title=Classification of idiopathic toe walking based on gait analysis: development and application of the ITW severity classification|journal=Gait & Posture|date=2007|volume=26|issue=3|pages=428–435|doi=10.1016/j.gaitpost.2006.10.011|pmid=17161602}} The Pomarino classification identifies the toe walking according to the individual's specific characteristics and characterizes them into three types based on the signs presented.{{cite journal|last1=Pomarino|first1=David|last2=Ramírez Llamas|first2=Juliana|last3=Martin|first3=Stephan|last4=Pomarino|first4=Andrea|title=Literature Review of Idiopathic Toe Walking: Etiology, Prevalence, Classification, and Treatment|journal=Foot & Ankle Specialist|date=16 January 2017|volume=10|issue=4|pages=337–342|doi=10.1177/1938640016687370|pmid=28092971|s2cid=3389265}}

Studies have been performed to determine the source of the association between toe walking and cerebral palsy. One study suggests that the toe walking—sometimes called an equinus gait—associated with cerebral palsy presents with an abnormally short medial and lateral gastrocnemius and soleus—the primary muscles involved in plantarflexion. A separate study found that the gait could be a compensatory movement due to weakened plantarflexion muscles.{{cite journal |journal= Journal of Applied Biomechanics |date=2003 |volume=19 |issue=4 |pages=325–339 |title= Equinus Deformity as a Compensatory Mechanism for Ankle Plantarflexor Weakness in Cerebral Palsy |author= Hampton, DA, Hollander, Kw, Engsberg, JR |url=http://journals.humankinetics.com/AcuCustom/Sitename/Documents/DocumentItem/2588.pdf |access-date=2013-12-11|doi=10.1123/jab.19.4.325 }} In people who have cerebral palsy and toe walk, there is greater plantarflexion force required for normal heel-to-toe walking than for toe walking. When typically developing children are tasked to perform different types of toe walking, their toe walking could not reduce the force to the levels that children who toe walking with cerebral palsy have when they walk. This suggests that toe walking associated with cerebral palsy may be due to abnormally weakened plantarflexion that can only manage toe walking.{{cite journal |journal= Journal of Biomechanics |date=2004 |pages=1321–7 |title= Gastrocnemius and soleus lengths in cerebral palsy equinus gait: differences between children with and without static contracture and effects of gastrocnemius recession |pmid=15275839 |doi=10.1016/j.jbiomech.2003.12.035 |volume=37 |issue=9|last1=Wren |first1=T. A. |last2=Do |first2=K. P. |last3=Kay |first3=R. M. }}

Toe walking after CSF glucose levels decrease is the representative symptom of those with GLUT1 deficiency Syndrome.{{cite journal| author=Sandu C, Burloiu CM, Barca DG, Magureanu SA, Craiu DC| title=Ketogenic Diet in Patients with GLUT1 Deficiency Syndrome | journal=Maedica (Bucur) | year= 2019 | volume= 14 | issue= 2 | pages= 93–97 | pmid=31523287 | doi=10.26574/maedica.2019.14.2.93 | pmc=6709387 }}

There are many health professionals who assess and treat toe walking. Family physicians, neurologists, orthopaedic surgeons, pediatricians, physical therapists, physiotherapists and podiatrists are all commonly consulted. Treatment will depend on the cause of the condition.{{cite web |url=http://www.orthoseek.com/articles/toewalk.html |title=Toe Walking |publisher=orthoseek.com |access-date=2007-06-07 |url-status=live |archive-url=https://web.archive.org/web/20070919235923/http://www.orthoseek.com/articles/toewalk.html |archive-date=2007-09-19 }}

For idiopathic toe walking in young children, health professionals may prefer to watch and wait: as the child may "outgrow" the toe walking with time.{{cite web |url=http://www.mastersofpediatrics.com/cme/cme2005/lecture30_1.asp |title=Toe Walking |publisher=mastersofpediatrics.com |access-date=2007-06-24 |url-status=dead |archive-url=https://web.archive.org/web/20070608193953/http://www.mastersofpediatrics.com/cme/cme2005/lecture30_1.asp |archive-date=2007-06-08 }} There are limited treatments that demonstrate long term walking change. Many treatments instead focus on any tightness in the calf muscles that can be associated with the toe walking.{{cite journal |last1=Caserta |first1=A |last2=Pacey |first2=V |last3=Fahey |first3=M |last4=Gray |first4=K |last5=Engelbert |first5=R |last6=Williams |first6=C |title=Interventions for idiopathic toe walking |journal=Cochrane Database of Systematic Reviews |date=2019 |volume=2019 |issue=10 |pages=CD012363 |doi=10.1002/14651858.CD012363.pub2|pmid=31587271 |pmc=6778693 }}{{cite web |url=http://www.emedicine.com/orthoped/topic451.htm |title=Toe Walking |publisher=emedecine.com |access-date=2007-06-07 |url-status=live |archive-url=https://web.archive.org/web/20070601015552/http://www.emedicine.com/orthoped/topic451.htm |archive-date=2007-06-01 }}

Common treatments for idiopathic toe walking can include:

• Wearing a brace, splint or type of orthoses either during the day, night or both. The brace limits the ability of the child to walk on their toes and may stretch muscle and tendon at the back of the leg. One type of orthoses commonly used are an AFO (ankle-foot orthoses).
• Serial casting, where the leg is cast with the calf muscle stretched. The cast is changed weekly with progressive stretching. Sometimes, these casts are not be changed weekly and instead every 2–3 weeks.
• Botox therapy may be used to paralyze the calf muscles to reduce the opposite of the muscles to work harder. This may be used with serial casting or splinting, however, one small study has shown this has limited impact.
• If conservative (non-surgical) measures do not help with changing the walking or making the calf muscles longer and correcting the toe walking after about 12–24 months, surgical lengthening of the tendon is an option. The surgery is typically done under full anaesthesia but if there are no issues, the child is released the same day. After the surgery, a below-the-knee walking cast is often worn for six weeks and then an AFO is worn to protect the tendon for several months.

For toe walking which results from other medical conditions, additional specialists may need to be consulted.

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{{Medical resources

| ICD10 = {{ICD10|R|26|8|r|26}}

| ICD9 = {{ICD9|781.2}}

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Category:Foot diseases