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Idiopathic Toe-Walking in Children
and Adolescents
Diagnosis, Natural History, and Treatment Options
Abstract
» Idiopathic toe-walking is a diagnosis of exclusion.
Halle D. Freiman, MS, MD
Curtis Mensah, MS
» The natural history of idiopathic toe-walking has not been studied in
many children; we identified only 1 prospective study. Of children
without equinus contractures who were toe-walking before the age of
5.5 years, 59% had spontaneous resolution of toe-walking by 5.5 years
of age, and 79%, by the age of 10 years.
Jason Codrington, BS
Steven L. Frick, MD
Investigation performed at the Stanford
University School of Medicine, Palo
Alto, California
» Adverse consequences of toe-walking into adulthood have not been
reported, but may exist, and further research is needed to define and
clarify.
» If parents desire treatment to resolve their child’s toe-walking,
surgical lengthening of the Achilles tendon is the treatment with the
highest chance of success and lowest relapse rate, and thus far, no
complications have been reported in any surgical series.
I
diopathic toe-walking (ITW) is an
abnormal gait pattern whereby the
child walks on the balls of their feet,
skipping the heel strike during the
initial stance phase that occurs in a normal
gait. ITW can be associated with contracture of the Achilles tendon, resulting in
limited range of motion of the ankle;
however, many children with ITW have no
contracture1,2. Toe-walking commonly
presents in children ,2 years of age as they
are developing walking abilities. Children
who always walk on their toes and cannot
ever get their heels to touch the floor when
standing typically have Achilles tendon
contracture and may have a condition
referred to as hereditary Achilles tendon
contracture3. The term congenital “short
tendo calcaneus” was first associated with
toe-walking by Hall et al. in 1967, and
children with contractures should be distinguished from children with ITW, where
substantial contractures are unusual4. The
child’s gait pattern matures over the first
COPYRIGHT © 2022 BY THE
JOURNAL OF BONE AND JOINT
SURGERY, INCORPORATED
JBJS REVIEWS 2022;10(2) :e21.00193
few years of walking, with adult kinematics
usually reached by the age of 3 years, and
during this time, toe-walking may spontaneously resolve5. Persistent toe-walking
after the age of 2 years can be an early
identifier of an underlying neuromuscular
etiology, and an evaluation to consider
cerebral palsy or muscular dystrophy is
warranted6. ITW is diagnosed when no
underlying pathology can be identified for a
patient who has initial contact on the
forefoot, with little to no heel strike, and has
no associated muscle weakness or decreased
reflexes or sensation7. Furrer and Deonna
analyzed “persistent toe-walking” in 28
children, and failure to explain this abnormal gait pattern with known disease
processes was diagnosed as “habitual toewalking.”8 Today, the literature most
commonly uses the term “idiopathic toe
walking,” with continued questions about
its etiology, natural history, and appropriate treatment9. Some studies report a higher
incidence of ITW in children with autism
Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online
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· http://dx.doi.org/10.2106/JBJS.RVW.21.00193
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spectrum disorder, and thus far, the
pathophysiology of this association is
unexplained6,10.
Normal Anatomy, Gait, and Ankle
Range of Motion
Most children diagnosed with ITW have
completely normal anatomy, with a
normal neurological examination and
no muscle weakness or contractures.
The important muscles to examine for
contracture are the gastrocnemius and
soleus. The distal fusion of these 2
muscles gives rise to the Achilles tendon
and together form the triceps surae
muscle-tendon complex that is responsible, primarily, for ankle plantar flexion
and secondarily, knee extension when
the foot is planted (ankle plantar flexionknee extension couple)1. Normal gait
consists of a heel-toe pattern with 3
ankle motion rockers (or phases) present
during the stance phase of the gait cycle.
The first rocker is initiated with a heel
strike and the ankle dorsiflexed, and is
abnormal in children with ITW. Normal ankle range of motion for typically
developing children during the gait cycle
is reported to be from 25° of dorsiflexion
to 15° to 20° of plantar flexion5. Stiffness
or contractures that limit this range of
motion can cause an abnormal gait.
Etiology
Normal walking is a coordinated function of the central nervous system
(CNS), with unconscious neurological
processes controlling multiple muscle
contractions and relaxations across
many joints, while also monitoring joint
and body positions to maintain balance
and forward momentum. It is best
described as a “controlled fall,” with
most muscles contracting eccentrically
during normal walking11. When discussing toe-walking with concerned
parents, the senior author tells parents
that children “walk with their brains and
spinal cord, not with their feet.” Explaining it this way can help parents
understand that their child is not doing
it consciously, and thus constant
reminders for the child to put their feet
on the floor during walking, and
2
instructions to “walk normal,” are not
going to change the unconscious CNS
abnormality. Why the CNS instructs
some children to toe-walk is unknown;
however, persistent toe-walking over
time may result in limited ankle dorsiflexion2. There is also a potential genetic
component to ITW; Pomarino et al.
reported that 42% of 836 children
with ITW had a family history of toewalking, with a possible autosomaldominant inheritance pattern, but
further investigation is needed12.
Diagnosis
ITW is a diagnosis of exclusion, and
therefore, several components of the
patient history and physical examination
are needed to rule out an underlying
cause of toe-walking; in rare instances,
further diagnostic studies (magnetic
resonance imaging [MRI] of the CNS,
nerve conduction tests, and computerized gait analysis) may also be needed.
Patient History
The history of a patient presenting with
toe-walking should highlight the main
concerns of the patient’s family, and
whether the child has issues with pain,
shoe-wear, running, tripping, keeping
up with peers, and/or cosmetic concerns. Parents often have concerns about
their child’s future function, possible
pain, and potential impact on other
joints. A detailed account of gestation,
birth, and developmental milestones
(both motor and communication skills)
are key aspects of the history. Toewalking may be a sign of cerebral palsy,
and it can also be an early sign of muscular dystrophy, where prompt diagnosis may allow for genetic analysis and
family counseling and is thus important.
An increased prevalence of toe-walking
has been noted in autism spectrum disorder, and delayed motor and speech
milestones may assist in making this
diagnosis6,10. Family history should
note any family member with a history
of toe-walking and/or gait abnormalities
or any neuromuscular conditions. Gait
history should include the age at which
the patient began to walk and include
details about the onset of toe-walking
and frequency (always, most of the time,
occasionally). It is important to confirm
whether the patient can achieve a flatfoot
position during walking.
Physical Examination
Physical examination of the patient
should include a full neurological and
musculoskeletal examination. Observational gait analysis should assess for
foot position during the swing phase
and at initial contact, foot position
throughout the stance phase, and evaluation for symmetrical arm swinging.
The extremities should be assessed for
any abnormalities, such as limited range
of motion, strength deficits, limb-length
discrepancies, or thigh/calf asymmetry.
Assessment for contractures of the ankle
has been used to differentiate habitual or
dynamic toe-walking from a fixed
deformity caused by Achilles contracture. If limited ankle dorsiflexion is
noted, the Silfverskiöld test can distinguish between isolated gastrocnemius
contracture and triceps surae contracture (comparing ankle dorsiflexion
measured with the knee flexed to 90° and
the measurement in knee extension).
Assessing the plantar callus pattern of the
feet provides information about whether
or not the heel is in contact with the
ground frequently during walking; in a
child who walks with a normal first ankle
rocker, the heel will have thick, glabrous
skin over the heel similar in color,
thickness, and roughness to the skin
beneath the metatarsal heads. In contrast, a patient who walks only with the
forefoot touching the ground will have a
widened forefoot compared with the
heel, with thickened callus beneath the
metatarsal heads and soft, paler skin over
the heel as the body adapts to concentration of pressure under the forefoot
(Figs. 1-A and 1-B). Knee and ankle
range of motion should be assessed. Assessing the patient’s ability to squat can
provide information on the functional
range of ankle dorsiflexion. Specific
evaluations for spasticity include assessments for hyperreflexia, clonus, and the
ability to accommodate rapid stretching
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Fig. 1-A
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Fig. 1-B
Figs. 1-A and 1-B Plantar surface of the foot of an 11-year-old girl with ITW. Morphological changes in the feet of toe-walking children include thickened
callus under the metatarsal heads, a widened forefoot, and a narrow heel. The standing plantar-pressure view shows pressure under the forefoot bilaterally.
as in the Duncan-Ely test for spasticity of
the rectus femoris13. Another physical
examination finding that can highlight
CNS abnormalities is the ability of the
patient to selectively control active dorsiflexion and plantar flexion of the
toes14; the inability to actively dorsiflex
and plantar flex the toes on command
should prompt an evaluation for a neurological cause of toe-walking. The gait
examination should include asking the
patient to heel-walk only, to assess for
active ankle dorsiflexion range of motion
and strength. Asking the patient to run
allows assessment of the ability to change
the pace of gait and the ability to swing
both arms. An inability to symmetrically
swing the arms with upper-extremity
posturing during running can be a sign
of hemiplegic cerebral palsy2. All
patients ,5 years of age with a presenting concern of toe-walking should be
asked to sit and rise from the floor to
assess for subtle proximal muscle weakness often seen in muscular dystrophies.
A positive Gower sign is noted if the
patient has difficulty rising, and uses the
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upper extremities to push on the thighs
to extend the hips or uses them to “climb
up the legs” to gain an erect posture15.
Diagnostic Testing
Laboratory and imaging studies can
identify pathological causes of toewalking. Assessment of creatine phosphokinase (CPK) is a simple screening
test for myopathies, and genetic testing
or muscle biopsy may be warranted if
muscular dystrophy is suspected. In the
setting of rigid equinus deformity, radiographs of the foot and ankle can rule
out skeletal malformations or congenital
fusions. Computerized video gait analysis and electromyography studies have
been reported to help differentiate ITW
from other neuromuscular causes16. If a
CNS abnormality is suspected, MRI of
the brain and/or spinal cord can assist in
ruling out brain malformations or neoplasms, Chiari malformation, syrinx,
and a tethered spinal cord as possible
etiologies17.
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Natural History
The natural history of ITW has not been
extensively studied. Hirsch and Wagner
observed 16 nonoperatively treated
patients until at least 13 years of age.
Two were excluded as they eventually
had an Achilles lengthening. All patients
received passive stretching exercises
aimed at increasing the length of the
triceps surae, and 5 were treated with
below-knee plaster casts for 2 to 4 weeks.
Three of the 5 were administered night
splints after cast removal. At the time of
follow-up, 11 of the patients were assessed in the clinic. The remaining 3
patients completed a survey and noted
no recurrence of toe-walking. Of the 11
patients seen in person, 3 did toe-walk
but had the ability to walk with a normal
gait, and 8 walked with an initial heelstrike pattern. None had improved
ankle dorsiflexion. The authors concluded that nonoperative treatment did
not have a long-lasting effect, and indicated that the natural history of ITW
was incomplete resolution of toewalking into adulthood 18 .
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A large, population-based cohort
study of ITW was reported by Engström
and Tedroff in 2018. Among 1,401
children with no known motor or neurodevelopmental conditions, 63 (4.5%)
walked on their toes or had been toewalkers at any time up to the age of 5.5
years. Twenty-six of the 1,401 children
were still toe-walkers at the age of 5.5
years. At 10 years of age, 8 of the 1,401
were still toe-walkers, while 5 had
undergone surgical lengthening of the
Achilles tendon between 5.5 and
10 years of age. Thus, 50 (79%) of 63
children who were toe-walkers at any
point prior to the age of 5.5 years had
spontaneously ceased toe-walking by 10
years of age. In this large cohort study of
ITW, no patient developed an Achilles
contracture2. The further natural history of the 8 patients for whom ITW did
not spontaneously resolve is unknown.
A critique of this study by Reinker raised
further questions regarding the natural
history of ITW, as the population
studied included only 63 patients, and a
gap was noted in our understanding of
spontaneous ITW resolution during
adolescence19. Articles and book chapters on ITW state that toe-walking
resolves in many/most cases with
increased age, and that in patients in
Fig. 2
The same 11-year-old girl with ITW as in Figs. 1-A
and 1-B. The patient has limited ankle
dorsiflexion in knee flexion, confirming the
development of an Achilles tendon
contracture.
4
whom it does not resolve spontaneously,
either nonoperative or operative interventions can be beneficial2,20. In addition to the infrequently studied and
poorly defined natural history, the
indications for treatment are unclear, as
the consequences of prolonged or permanent toe-walking gait have not been
fully documented. Dietz and Khunsree
considered toe-walking a cosmetic
deformity that should be treated only if
the gait pattern troubles the family, and
noted a quote from a 2006 article by Eiff
et al. that remains true today: “There is
no convincing evidence that any treatment is necessary for toe-walking”21,22.
The risks and benefits of operative and
nonoperative treatment are also
unclear22.
Consequences of Continued ITW
Literature on the long-term consequences of toe-walking in adolescence
and adulthood is scarce. The senior
author often hears parental concerns
about future foot, knee, hip, and back
function or disability. We were unable
to find studies with long-term follow-up
into adulthood in which these concerns
were confirmed or denied. Dietz and
Khunsree noted that their adult foot and
ankle colleagues did not see adults with
foot concerns related to childhood toewalking22. Sobel et al. examined 60
patients who toe-walked, ranging in age
from 1 to 15 years20. Patient complaints
included falling, in-toeing, pain, fatigue,
flatfoot, limping, poor balance, and
bunions. In their study, Sobel et al.
noted that 46% of patients with ITW
had ,0° of passive ankle dorsiflexion,
and they found decreased dorsiflexion as
age increased. They concluded that
ankle equinus contractures may develop
as a consequence of prolonged toewalking8,20 (Fig. 2).
From our review of the literature,
rocker-bottom foot deformity (RBFD)
has not been reported among patients
with a history of ITW but has been
reported among patients with cerebral
palsy, clubfoot, peroneal spasticity,
flatfoot, and Charcot arthropathy23-25.
No report of a patient with ITW
describes the development of RBFD or
any of its consequences, or adverse
effects on knee, hip, or back function.
The treating surgeon thus may be well
advised to not tell parents that there are
long-term adverse consequences of
continued toe-walking, such as foot
arthritis, ankle arthritis, knee arthritis, or
hip arthritis, as there is no evidence yet to
support these concerns22. Recent studies
note that the abnormal walking pattern
has the potential to change foot morphology, with an abnormal shape of the
talus, a widened forefoot, and a small
and narrow hindfoot26,27. This can be
quantified by the forefoot splay index
measurement described by Davids et al.:
forefoot width divided by hindfoot
width28, with an increase in this ratio in
children with ITW compared with the
normal population27. This change in
skeletal development can affect shoewear choice for the patient, and the more
concentrated pressure distribution on
the forefoot may lead to metatarsalgia in
patients with ITW who develop contractures, as DiGiovanni et al. reported
forefoot pain in 56% of adults with
gastrocnemius contractures29. Compensation for toe-walking can lead to
out-toeing to assist foot clearance, and
the development of increased external
rotation has been reported28,30. After a
tendo Achilles lengthening, this may
become more obvious and may even
require a corrective osteotomy28,31. The
potential long-term consequences of
persistent toe-walking require more
investigation.
Treatment Options
Nonsurgical treatment options reported
for ITW include bracing, botulinum
toxin (Botox; Allergan) injections, serial
casting, and physiotherapy (PT). The
results reported for nonoperative therapy are mixed. While gait improvement
is reported for each of these treatment
modalities, it seems to be minimal,
and in many cases, patients revert to
toe-walking after short-term improvement32,33. There is a lack of welldesigned or controlled studies of bracing
alone to treat ITW. Bracing is often used
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as an adjunct with other treatment
options such as Botox, PT, or surgery.
Bartoletta et al. performed a retrospective review of nonoperative treatment
methods, and 103 of the 204 children
were given ankle foot orthoses (AFOs).
They found that AFO treatment
was the only method associated with
improvement. At the last follow-up, 55
children had successful outcomes and all
had used AFOs at some point in their
treatment34.
Botox injections into the gastrocnemius for the treatment of ITW have
been studied, with successful resolution
of toe-walking noted by Sätilä et al. and
Brunt et al.32,35, but a randomized
controlled trial by Engström et al.,
which included a group of 15 children
between 5 and 13 years of age, found
that Botox alone was not an effective
treatment. Eleven of the 15 patients
completed follow-up at 12 months, and
only 3 of the 11 completely ceased toewalking. Four children decreased their
toe-walking from 100% to 50%, 100%
to 75%, 75% to 50%, and 75% to 25%,
respectively36. A follow-up study by
Engström et al. combined the use of
Botox injections with serial casting. The
authors found no significant difference
between the Botox and control groups at
any time period and concluded that
adding Botox injections prior to cast
treatment did not improve the outcome33. These studies cast doubt on any
utility for botulinum toxin in ITW
treatment.
There is not a published standardized casting protocol for ITW, but
most articles and book chapters recommend bilateral below-the-knee serial
walking casts set in slight dorsiflexion,
changed at 2 to 4-week intervals. Following casting, there is often a time
period with intensified PT and night
splints; however, these techniques have
led to mixed results. Katz and Mubarak
examined 7 toe-walkers with an average
age of 7 years. Five underwent serial cast
treatment that included bilateral belowthe-knee, dorsiflexion cut-out walking
casts for 7 weeks. Two of the 7 continued
to toe-walk, and 5 improved. Two years
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after treatment, maximal ankle dorsiflexion increased 6° from the values
measured at the termination of the primary treatment3. A 2004 study by Stott
et al. included 13 patients who had been
treated as children for ITW and underwent gait analysis and calf-muscle
strength testing for follow-up after
intervention. Six had serial casting only,
and 7 had surgery. The patients who
received cast treatment had bilateral
below-the-knee serial walking casting
for 6 weeks, followed by home passive
stretching exercises. The 6 patients with
cast treatment reported improvement in
toe-walking, and all but 1 had visually
normal gait, although no child had
normalized gait kinematics30. Eastwood
et al. found that, despite parental perception of improvement being reported
for 51% of patients treated with cast use,
physician observation showed that only
22% of patients had a normal heel-totoe gait37. Fox et al. reported that 29 of
44 patients with cast treatment had
completely resolved toe-walking at a
mean follow-up of 14 months, with 15
continuing toe-walking after bilateral
serial casting for 5.7 weeks38. In another
cohort of 13 patients with serial walkingcast treatment, 40% continued to toewalk according to the parental report39.
Although serial casting has yielded some
reported improvements, a high percentage of patients treated with use of
casting continue to toe-walk, and the
rate of relapse increases over time.
The role of PT for ITW is not fully
understood, as there are minimal data on
PT employed without the incorporation
of other treatment modalities. Clark
et al. reported that 5 patients had
improvement and 1 child had an
increase in heel-strike frequency. The
parents reported minimal gait change40.
Of 14 patients examined by Hirsch and
Wagner, 9 were treated with PT that
included passive stretching exercises of
the calf as well as home exercises to
improve active dorsiflexion. Eight of the
patients showed complete resolution of
toe-walking as noted by physician
observation and parental reporting at a
mean follow-up of 14 years18.
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Surgical treatment of ITW
includes gastrocnemius lengthening
(zone I), gastrocnemius lengthening
with the soleus fascia also lengthened
(zone II), or percutaneous or open tendo
Achilles lengthening (TAL) (zone III).
In toe-walkers, the triceps surae complex
is in a shortened length throughout the
gait cycle, and lengthening it should
promote heel contact during gait. In
addition, TAL may weaken plantar
flexion temporarily, making toe-walking
difficult or impossible for a few months
after surgery. Breaking the pattern of
continuous toe-walking may allow reprogramming of the CNS to then allow
for a normal heel-toe gait pattern to
become permanent. In the 1 prospective
study that we identified evaluating the
natural history of ITW, 8% of patients
underwent surgery prior to 10 years of
age, although the indications for surgery
and the outcomes were not reported2.
TAL surgical procedures are simple
and effective with minimal complications, with many surgical methods
reported to lengthen the triceps surae
complex. Stricker and Angulo compared
treatment among 3 groups who had
undergone observation, casting/AFO
use only, and surgery, respectively. The
surgical group included 15 patients: 11
with bilateral Achilles Z-plasty lengthening and 4 with bilateral gastrocnemius
recession. Among the 3 groups, the
surgical group had a 20° improvement
(from 210° to 10°) in ankle dorsiflexion,
and only 1 patient continued to toewalk41. Hemo et al. retrospectively
analyzed 15 patients with ITW, 12 of
whom experienced failure of nonoperative measures (serial casting, AFO use,
PT). The outcome measurements
included passive range of motion, plantar flexion strength, and gait analysis
preoperatively and 1 year after surgery. Twelve patients underwent open
TAL and 3 underwent percutaneous
TAL, and 12 of 15 had complete resolution of toe-walking, whereas 3 had
normal gait most of the time but still
occasionally walked on their toes42.
Similarly, McMulkin et al. retrospectively reviewed 14 patients who had
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undergone surgical treatment for ITW
(7 TAL: 6 percutaneous and 1 open
Z-lengthening, and 7 gastrocnemius
lengthenings). Peak knee flexion was
normalized in the TAL group, and dorsiflexion was significantly improved in
both groups43. McMulkin et al. later
studied 8 patients who had surgical
lengthening of the gastrocnemius/
soleus. Five years after surgery, gait
analysis demonstrated improvements in
pelvic tilt and ankle dorsiflexion during
stance and swing phases. Ankle plantarflexion power peak values significantly
improved from before surgery to the 1-year
follow-up (from 0.83 to 1.10 Nm/kg)44.
Further improvement was noted at
5-year follow-up, from 1.10 to 1.31
Nm/kg. Overall kinematic improvements were maintained 5 years postsurgery in all 8 patients44. Kogan and
Smith’s analysis of 10 surgically treated
patients with ITW found that percutaneous TAL is extremely effective, with a
predictable outcome, smaller scars, and
less time spent in casts as compared to
traditional open TAL. None of the
patients had any recurrence of toewalking, regardless of the age at initial
treatment45. Westberry et al. concluded
that those with severe ITW treated
initially with a zone-III lengthening
have more successful outcomes, no
increased risk of overlengthening, no
need for additional interventions, and a
decreased rate of recurrence. Zone-III
procedures were a mix of open Zlengthening, percutaneous Hoke TAL,
and open Hoke lengthening. After an
average of 3.6 years, no zone-III patients
needed additional treatments, operative
or nonoperative28. The main concerns
with surgical lengthening of the Achilles
tendon are overlengthening and permanent weakening, with loss of the
ankle plantar flexion-knee extension
couple, possible inability for the patient
to walk on their toes, or the development
of crouch gait. Multiple authors have
specifically looked for overlengthening
after TAL for ITW, and it has not been
found28,39. It is also important to consider the possible risks associated with
any lower-extremity surgical procedure,
TABLE I Literature on Surgical Treatment of ITW*
Study
Stricker and Angulo41 (1998)
No. of Participants
Mean
Who Underwent
Age at
Surgery
Surgery (yr)
15
3.9
Type of Intervention
TAL (bilateral Z-plasty), 11
Gastrocnemius recession, 4
Followed by cast and AFO for
2-6 months
Kogan and Smith45 (2001)
Stott et al.30 (2004)
10
7
Not
available
10.5
Percutaneous TAL
15
9
TAL (bilateral), 5
TAL (bilateral): percutaneous, 3
and open, 12
Followed by below-the-knee
casting and AFO use
McMulkin et al.43 (2006)
14
9.3
McMulkin et al.44 (2016)
8
9
14 with complete resolution
and 1 continued to toe-walk
but showed improvement
3
10 with complete resolution
3.4
6 with complete resolution
and 1 occasionally walked on
toes when not being
observed
10.8
12 with complete resolution
and 3 with normal gait most
of the time but occasionally
walked on toes
2.9
Followed by below-the-knee
walking casts for 4 weeks
Gastrocnemius lengthening, 2
Hemo et al.42 (2006)
Results of Surgical
Intervention
Mean Time to
Follow-up for
Surgically Treated
Patients (yr)
TAL: percutaneous, 6 and open, 1 14 with improvement in all
gait parameters
Gastrocnemius lengthening, 7
11
TAL, 4
8 with improvement in all gait
parameters
5
21 extremities with complete
resolution after zone-III
lengthenings (100%)
3.6
Gastrocnemius lengthening, 4
Followed by casting for 4 weeks
Westberry et al.28 (2021)
26
9.9
Zone-II and zone-III TAL
25 extremities with complete
resolution after zone-II
lengthenings (88%)
*All patients in the published surgical series demonstrated notable improvement, and there were no reported surgical complications. Specifically, no
wound-healing problems, Achilles tendon rupture, plantar flexion weakness, or crouch gait were reported.
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such as venous thromboembolic disease,
poor wound-healing, or damage to
nearby nerves or vascular structures46.
To our knowledge, none of these concerns or complications have been
reported after TAL for ITW. Relapse
rates after surgery are low, but there are
limited surgical series reporting relapse
rates with mid to long-term follow-up
(Table I).
Conclusions
ITW is a diagnosis of exclusion with an
unknown cause. It is common for children ,2 years of age to walk on their
toes, but if this abnormal gait continues
after reaching 2 years of age, evaluation
for a possible neuromuscular cause is
warranted. Most children who toe-walk
spontaneously develop a heel-toe gait
pattern, but the natural history of toewalking is poorly understood; adverse
functional consequences of prolonged
toe-walking have not been reported, but
further research is needed to define and
clarify. Toe-walking is a cosmetic and
social concern in childhood, but recent
literature shows morphological changes
of the foot and the development of
equinus contractures in patients with
ITW that, as is seen with other orthopaedic conditions, may have an adverse
effect on long-term foot function20,26.
There is currently no widely accepted
protocol for the treatment for ITW, with
possible interventions including bracing, PT, use of botulinum toxin, serial
casting, and tendon/muscle lengthening
surgery. While nonoperative treatments
avoid surgical and anesthetic risks, their
effectiveness in published studies is
poor, and the longevity of a normal gait
following these treatments is not well
documented. Surgical lengthening of
the Achilles tendon, however, results in
the most consistent and successful outcomes, and thus far, no surgical complications have been reported. Literature
reports of surgically treated patients
show complete resolution of, or notable
improvement in, toe-walking. The
excellent results with no morbidity
reported for zone-III lengthenings, and
the simplicity and effectiveness of per-
FEBRUARY 2022
cutaneous TAL, have made this the
preferred treatment option for some
authors28,45. This treatment is offered to
parents of toe-walking children $5 years
of age when the family finds the gait
pattern troubling and they desire an
effective treatment. More research is
needed focusing on the population of
adolescent toe-walkers with no spontaneous resolution and assessing whether
morphological changes and the development of contractures noted in toewalking adolescents have functional
consequences. Larger cohorts and longer
follow-up periods are essential to developing an evidence-based approach to the
treatment of ITW.
Source of Funding
No funding was received for this
manuscript.
Halle D. Freiman, MS, MD1,
Curtis Mensah, MS2,
Jason Codrington, BS3,
Steven L. Frick, MD1
1Stanford University School of Medicine,
Palo Alto, California
2Meharry Medical College, Nashville,
Tennessee
3University
of Miami Miller School of
Medicine, Miami, Florida
Email for corresponding author:
sfrick01@stanford.edu
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