Toe walking is a condition in which children from the age of 2 and older have a tendency to walk on the front of the foot (ball and toes) instead of striking the heel to the ground. Depending on the severity, some children will walk on their toes at all times, and others only at certain times, such as when running. A great portion of children that toe walk can stand still with their feet flat on the ground, but will initiate toe walking as soon as they are ambulating.
Toe Walking in Cerebral Palsy:– is one of the most common motor impairments in children and adults. It also occurs in other diseases and disabilities. The impairment is often indicating with shortening of the calf muscles with the bone misalignments of foot and ankle joints.
Such deformities are worsened during growth which may need to be surgically corrected if severely affected and stiffened.
Habitual Toe Walking:– is common for children under three years of age. As the child gets older, it should start walking, using the entire base of the foot, including the heel. Sometimes however the child continues to ‘toe walk’. It might be caused by a short Achilles tendon, which attaches the calf muscle to the heel. This causes tightness in the calf muscle, which raises the heel and prevents it from touching the ground when walking. Parents also often ask, does walking on tiptoes indicate autism? Many children with autism find it difficult to bend their ankles beyond 90 degrees, forcing them to walk on tiptoes. Many studies of children with autism have shown that they have issues with gait or walking alignment.
Apart from simple observation by a parent, a pediatric surgeon or doctor can perform a physical examination to identify the biomechanics which cause the toe walking and the severity of the condition. This includes spasticity, tight or shortened muscles or tendons, as well as bony deformity.
I most cases, the cause for toe walking is unknown and can be due to growth irregularities. But in some cases, it can be as a result of a neuromuscular disease or disorder, such as Cerebral Palsy, Muscular Dystrophy or even Autism. It is therefore important that upon first diagnosis, the child is assessed by a neurologist to rule out any underlying neuromuscular conditions.
Apart from neurological conditions, malnutrition, lack of activities and vitamin D deficiency all affect normal physiological development and growth, and these contributing factors also need to be monitored and rules out.
Treatment of this condition involves stretching and lengthening of muscles and tendons and repositioning of bony structures. Depending on the severity of the condition, treatment for toe walking can range from a basic positioning device for night time use, to surgery or a combination of surgery and orthopedic bracing.
Children with neuromuscular conditions, who suffer from high tone and possible deformity will often require comprehensive treatment. This is usually done by performing a surgical muscular or tendon lengthening to release the tension and improve ranges of motion of the ankle. This is followed by serial casting by which the ankle is kept in the corrected position by means of a rigid cast for a period of 3 to 6 weeks. The cast may be removed and replaced with a new cast as the positioning improves.
Once the above process is complete and the child is fully healed, custom manufactured ankle foot orthoses are provided for use during night time, and an additional pair is provided to use during daytime to continue the stretching process and prevent loss of the newly gained ranges of motion. These two devices maintain good ankle ranges, whilst repositioning bony structures, effectively keeping the heel down and maintaining stretch to the affected areas.
In milder cases, such as the idiopathic cases with no underlying neuromuscular conditions, no surgery may be required, and only a brace to use during the day or night time is required. In other cases, surgery may not be required, but serial casting is required, followed by provision of an ankle foot orthosis.
Surgery should be avoided wherever possible, and it is the responsibility of the pediatric orthopedic surgeon and neurologist to determine what is the least invasive and most effective treatment.
Physiotherapy is required after serial casting is completed or once the ankle foot orthosis is provided, during which the child is stretched routinely, and also educated and trained in the use of the new devices.
The orthotic devices should be adjusted by the orthotist as the ranges of motion improve and or as the child grows. It is therefore recommended that the patient is seen by the orthotist once every 3 months.