Toe Walking

Epidemiology

 

70% male

70% positive FHx

20% learning difficulties

 

DDx toe walking

 

Early / late onset

Unilateral  / bilateral

 

1.  Habitual

 

Toddlers - child can heel walk

 

2.  Structural

 

Fixed equinus - CTEV / arthrogryposis

Short / tight T Achilles

Space occupying lesion in calf

 

3. Neuromuscular

 

CP

Spinal dysraphism

Duchenne's Muscular Dystrophy

CMT

 

4. Short Leg

 

Real (DDH)

Apparent (knee or hip deformity)

 

Natural History Habitual

 

Initially toddlers walk on toes 3-6/12

- graduate to strike on flat of foot

- rinally develop normal heel-toe gait

- mature gait pattern by 3 years

 

Idiopathic Toe walker

- normally bilateral

- usually from birth

 

Beware 5 year old who has recently begun to toe walk, especially unilateral

 

History

 

Gestational 

Birth 

Family history

How long on tip toes ?

Walking age 

All the time or not ?

 

Examination

 

Rule Out

 

1. CP

2. Duchenne's MD

3. CMT

4. Short Leg / DDH

5. Dysraphism

 

Hip

- Trendelenberg 

- LLD

 

Spine 

- signs spinal dysraphism

- scoliosis

 

Gait

- Heel / Toe walk 

- running coordination - hemiplegic / brings out very minor posturing / look at UL

 

Gower's sign

- Duchenne's muscular dystrophy

- ask to squat then stand up

- have to hand walk up their legs as severe proximal muscle weakness

 

Upper limbs

- for hemiplegia, increased tone

 

Foot

- active +/- passive ROM 

- sole of foot - if always on toes then heel will be soft

- Silverskiold

 

Neurological exam 

- especially abdominal reflexes

 

Investigations

 

Spine Xray / MRI

 

Gait analysis 

 

EMG 

 

Serum CPK

- DMD > 5000

- proceed to muscle biopsy if elevated

 

Nerve biopsy - rare but may need in peripheral neuropathy

 

Management

 

Non Operative

 

Stretches 

Serial casting 

Botulinum A toxin in CP 

AFO 

 

Operative

 

Percutaneous T achilles lengthening 

 

Timing

- ? about 7 years or older

- wait till at least > 4 years

- many resolve by age 10

 

Results

- 75% will still toe walk after treatment