Toe Walking

• Toe walking, or when a child walks without their heel contacting the ground, can be part of normal / typical development, a sign of neuromuscular disease or associated with developmental or orthopaedic conditions. 
• When children under the age of 3 toe walk sometimes, it is commonly considered part of normal / typical development. After 3, all children who toe walk should be assessed to determine if there is a neurological, orthopaedic or developmental reason for the child’s gait.
• Toe walking assessment may be guided by a validated tool to guide referral or consideration of what reason the child might be toe walking

Further information about toe walking is available:

• Toe walking due to cerebral palsy
• Cochrane Review - Interventions for toe walking
  
• Toe walking due to an inherited neuropathy (Charcot Marie Tooth disease)

Idiopathic toe walking (or simply toe walking) can be observed in healthy young children and should resolve spontaneously by 3 years of age. Sometimes, however, toe walking may be pathological and careful joint, neuromuscular and developmental assessment is always necessary.  Toe walking can be associated with: 

• Developmental delay (need to assess speech, language, hearing, communication). Toe-walking gait can also be seen in children with Autism Spectrum Disorder (ASD).
• Neurological disease (consider Muscular Dystrophy, Cerebral Palsy).
• Inflammatory problems (consider Arthritis, Inflammatory Muscle Disease) resulting in a short Achilles tendon.
• Metabolic conditions (consider Mucopolysaccharidoses).
• Congenital abnormalities (consider Clubfoot, Developmental Dysplasia of the hip which can cause leg length discrepancy).

Management depends on the underlying cause - medications can help (e.g., botulinum injections), and rarely surgery are required.

• Common toe walking treatments supported by evidence include ankle or leg surgery, serial casting (with or without botulinum toxin injection), different types of ankle or foot orthoses, footwear modifications, targeted physical activity or strength activities, or watching and waiting.
• Toe walking treatments commonly target any tight muscle and aid to help the child participate to their fullest and gain or maintain leg muscle strength. It is important that the right treatment be matched to the reason why the child toe walks as some treatments may not work for toe walking from some conditions. Some children will also grow out of this type of walking. 

A careful history and neuromuscular, joint and developmental assessments are needed.

Key questions include:

• Does the child have pain in their feet or legs?
• Is there any morning stiffness or 'gelling' (a sensation of stiffness after periods of inactivity such as sitting cross-legged on the floor or after long car journeys)? Gelling can be a feature of inflammatory arthritis.
• Are there any functional problems (e.g., speech, hearing, feeding, or difficulties taking part in sport or play)?
• Assess motor development; is there a delay in motor milestones, or regression of achieved milestones?
• Has there been a change in mood or behaviour?
• Is the child clumsy (e.g., is there a tendency to fall over)?

Assessment should include the following:

• pGALS to assess all joints and pREMS for a detailed joint examination as necessary. 
• Assess gait – in muscular dystrophy tip-toeing is accompanied by an exaggerated lumbar lordosis, calf hypertrophy and a positive Gower’s test. In cerebral palsy there can be a diplegic or hemiplegic gait with upper extremity flexion posturing.
• Check muscle bulk - calf muscle (pseudo-) hypertrophy or wasting may suggest muscle or joint disease.
• Assess Achilles tendon for contracture (this can suggest muscle disease or neurological disease). Do this by checking that the foot dorsiflexes to more than 90 degrees (usually 95-100 degrees) and that both feet are symmetrical.
• Complete a neurological examination (tone, reflexes, power).
• Ask the child to stand, from sitting on the floor or squatting, without using their hands (if unable to do this, then it may suggest muscle disease - look for Gower's sign). A child who must use their hands to get up off the floor, usually by pushing against their own body (or walking-up their own body) is said to have a positive Gower test, or be demonstrating Gower’s sign.
• Ask the child to squat, or stand while their heels are on the floor (if they unable to do this, then it may suggest tight Achilles tendons).
• Examine the patient's shoes - look for excessive / asymmetrical wear and tear of the sole.

Indications for referral (general paediatrics / paediatric orthopaedics / paediatric neurology):

• Asymmetrical tip-toe walking.
• Delay or regression of milestones.
• Persistence beyond the age of 3 years.
• When a child can’t get their heel to the ground without changing how they stand, regardless of the child’s age, clinicians should also refer for specialist assessment
• If a child develops a new toe walking gait, has changes in their continence or groin sensation, urgent medical care is advised.
• Suspicion of joint or muscle disease (e.g., pain, swelling, stiffness, clumsiness, weakness; this may be suggested if toe-walking is new and a change from a previous gait pattern).
• Suspicion of autism spectrum disorder. 
• Family history of muscle disease.
• Children over the age of 3 years who are unable to:
• Stand from sitting on the floor without using hands (suggests proximal weakness).
• Squat or stand with their heels on the floor (suggests Achilles tendon tightness).
• Jump on both feet (should be achieved by school age child).

It is noteworthy that pGALS, V-pGALS and pGALSplus tools are assessment aids to prompt further investigations or referrals. Other tools are there to support collection of consistent and important information to aid clinical decision making, such as pREMS or the GALLOP Proforma (Gait and Lower Limb Observation of Paediatrics). 

Further information about GALLOP is available; 

pGALSplus builds on pGALS and aims to help clinicians to determine if a child with a musculoskeletal problem will need specialist referral or not and if so whether to rheumatology,  orthopaedics or neurology/neurodisability. A Model of Care involving triage is called RightPath which includes Triage guidance. 

Further information about RightPath is available