Idiopathic Toe Walking

Idiopathic toe walking is the most common form of toe walking. The word “idiopathic” means we don’t know what causes the condition. Toe walking is when children walk on their tiptoes. It is normal for some children, such as those age three and under who are learning to walk, to do so on their toes. The condition often goes away without treatment as children gain weight and get involved in weight-bearing activities. More activity makes the tendons and muscles in the heel stretch out, allowing heel-to-toe walking. It is important to know, however, that toe walking may be an indicator of another diagnosis, such as cerebral palsy.

When walking normally, the brain sends signals to the calf muscles. Muscle fibers are stretchy and can lengthen and shorten themselves. The brain signals tell the muscles to tighten and then relax, creating the motions needed to take a complete step. When a child toe-walks consistently, the muscles can lose their flexibility and stay shortened. This shortening of the muscles might cause slower running, tripping, falling and poor endurance. As adults, people who toe-walked as children might have foot pain, lack of balance and/or cosmetic concerns.

The goal of treatment is to stretch muscles and retrain brain signals so that your child’s walking changes from toe walking to heel-to-toe walking. Keeping muscles and the Achilles tendon stretched over time will allow the brain to relearn how to walk with the heels closer to the ground. Following the treatment your doctor prescribes can ensure a positive outcome. Your doctor will discuss several treatment options with you and help you make the best choice for your child.

Treatment might include:

• Observing the condition to see if it gets better or worse.
• Physical therapy to teach stretching and range-of-motion exercises to do at home.
• Splints—called ankle foot orthoses (AFOs)—to hold the foot and ankle in a stretched position.
• A series of ankle casts—called serial casts— which are changed every two weeks. These are usually worn for a total of 4 or 6 weeks to create a prolonged (lasting) stretch position. Children can walk and play as usual while the casts are on. AFO splints sometimes follow serial casting. This means working with our orthotics team.
• Injections into the muscle with a tone-reducing medicine, such as botulinum toxin. Casting and splints sometimes follow injections.
• Orthopedic surgery, which involves talking with an orthopedic surgeon

Botulinum toxin injections are often recommended for toe walking. If it is the choice for your child, treatment will be as follows:

1. Your child will receive injections into calf muscles. The procedure takes place in a clinic setting. Your child will like take an anti-anxiety medication or nitrous oxide (laughing gas). We may numb the skin with a cream that has lidocaine in it. There will be multiple injections in each calf. The procedure doesn’t take long, and side effects are rare. There are no restrictions after the procedure.
2. We apply short walking casts, which cover the foot and lower part of the leg below the knee. It takes up to three weeks for botulinum toxin to reach its full effect. After that, the heel cords stretch more easily. Children can walk and do their typical activities while in the leg casts. However, casts must be kept dry; that means your child cannot swim, shower, or take a tub bath while the casts are on. The casts will be changed every two weeks. When they are changed, the doctor will look at your child’s progress before putting on the next casts. Providers recommend casting for a total of 4 to 6 weeks. During the first two weeks, it is not uncommon for children to continue to walk on their toes in the casts.
3. After casts are removed, AFO splints may be recommended. AFOs are molded out of plaster and fitted when casting is complete. AFOs have a hinge that allows the foot to flex up, limiting downward flexing to 90 degrees or less. AFOs fit inside shoes. Wearing the AFOs is an important part of keeping the muscle stretched. A few children have toe walking return following treatment.

Talk with your doctor if you do not understand your child’s diagnosis, or if you have concerns about the treatment recommendations.