TOE WALKING

It is very natural for the parents to assume that persistence of toe walking is just a force of habit and nothing else. But we ‘docs’ at times need to rule out medical causes before attributing the condition to mere habit. Such children need a thorough assessment in form of a detailed history and a physical examination.
When a young child begins to walk, toe walking is common and is considered within a broad range of normal, particularly when the child can stand with his foot flat when not walking. During normal gait development, “heel strike” (1st event in gait cycle) should occur by the age of 3 yr. Persistent toe-walking past this age is abnormal and neurological causes like mild cerebral palsy need to be ruled out.
The other possible reason for this can be a shortened tendo-achilles tendon/ heel cord, which pulls the ankle and foot down (plantar flexion). When no cause is found for this, it is termed as ‘Idiopathic’. The condition thus, is called “Idiopathic Toe Walking” and may have been present in the older family members in their childhood.
Basis of treatment in both is to correct the deformity around the ankle and maintain it to allow a normal heel-toe gait pattern. One starts by stretching the tendo-achilles at regular intervals, using short-leg casts after stretching to maintain correction initially; followed by orthotic/brace support. In Idiopathic cases, surgical lengthening of heel cord is generally delayed for several years and is the last resort. The condition is known to take a long time to respond and patience needs to be in abundance. For toe walking due to mild cerebral palsy (CP), a proper rehabilitation program (physical and occupational therapy) in addition, needs to be tailored for the patient. As CP itself cannot be eradicated, its effect on lower limb joints needs to be monitored during growth, and managed accordingly. An appropriate controlled surgical release of gastro-soleus at the musculo-tendinous junction may be planned in certain cases at the right age. This is followed by maintenance of correction by casts initially and later by ankle-foot orthosis (AFO). The family needs to be thoroughly educated regarding the utmost importance of a persistent proper rehabilitation in terms of physical therapy and gait training.


Dr Ramani Narasimhan
Sr. Consultant Pediatric Orthopaedic Surgeon
Indraprastha Apollo Hospitals, New Delhi.
Mobile no: 09811016102