Toddlers from age 1 to about 3 yrs of age may often exhibit toe walking. By age 2 to 3 the toe walking should disappear. Persistent toe walking after age 2, especially toe walking on one leg may be a cause for concern. A common problem associated with toe walking is Cerebral palsy, Autism, and Duchenne Muscular Dystrophy to name a few. These underlying disorders should be identified early on. A neurological examination needs to be done, including a test for language and developmental delays. If there are no developmental delays or muscle spasticity, then your child has what is known as “idiopathic toe walking”.
The most common problem neuromuscular disorder amongst toe walkers is Cerebral palsy (CP), affecting 1-7 in 1000 children. Not all children afflicted with CP are toe walkers. Less than 50% of children with CP walk on their toes. Another cause is Duchenne Muscular Dystrophy, a paralytic muscular disease, where children typically will walk on their toes.Spastic CP results in muscle spasticity, and is a common cause of toe walking.
Muscle spasticity can result from Spastic CP as well as from Spinal Cord lesions. Spinal cord lesions can be congenital, traumatic or acquired. It is important for you to see your Podiatrist as well as your Pediatrician regarding these disorders.
If your child is otherwise healthy, without any neuromuscular disorders, then your child may have what is called “Idiopathic toe walking”. This simply means that there is no defined cause for the toe walking. Toe walkers under this category may just have a habit of walking on their toes. Others may have a congenitally short Achilles tendon. However toe walking may also be associated with a short Achilles tendon. Casting or physical therapy and even surgery may be necessary to stretch and lengthen the calf muscles of the shortened Achilles tendon.
A thorough physical examination must be done to evaluate where the deformity is originating from. The physical examination will determine where the spasticity or contracture of the Achilles tendon is coming from. Your Podiatrist or Pediatrician should be able to determine spasticity of the hamstrings or hip flexors. This exam may also involve a gait analysis or observation of your child walking at a regular pace.
Toe walking which is not neuromuscular in origin (called idiopathic toe walking), has several first line treatment measures which can be incorporated. Some of treatments for a short Achilles tendon include stretching exercises, casting and orthotics. Remember, a toddler, under the age of 3 should just be observed.
On modality that is non-surgical and has good results is the molded ankle-foot orthosis (MAFO). This device fits in a regular shoe or sneaker, and a calf sock will conceal the device effectively. The MAFO allows only specific motions while walking and prevents your child from toe walking, since it does not allow the heel to come off the ground. With every step your child takes, the Achilles tendon is stretched. Most children have to wear this device for 6 to 8 months.
Even while wearing this device, (the MAFO) in the shoes, regular stretching should be incorporated during the day. Your podiatrist or pediatrician can teach you these exercises to stretch the Achilles tendon regularly.
With more severe cases, serial casting may be necessary to stretch the Achilles tendon. These casts are changed weekly and the Achilles tendon is manipulated and stretched more with each cast.
Toe walking which is more severe or is due to an underlying neuromuscular disorder will not be corrected with the above modalities. Surgical intervention may be the next line of treatment. The most common surgical correction of the short Achilles tendon is lengthening of the tendon. Your podiatrist or pediatrician will determine whether the toe walking is isolated to the heel or if the knees and/or the hips are contributing to the toe walking. All this needs to be determined prior to performing any surgery.