Epidemiology
Differential diagnosis
Habitual - child can heel walk
| Structural | Neuromuscular | Leg length discrepancy |
|---|---|---|
|
Tight tendoachilles
Fixed equinus - arthrogryposis - clubfoot
|
Cerebral palsy Spina bifida Charcot-Marie-Tooth Duchenne's muscular dystrophy |
Short tibia / femur
Apparent LLD - hip and knee deformity |
Natural history
Habitual
Bilateral toe-walking normal first 6 months of walking
- graduate over time to heel strike
- normal gait by age 3
History
Concerning features
Child > 3
Unilateral
New onset
Examination
True leg length discrepancy - measure femur / tibia
Apparent leg length discrepancy - hip / knee ROM and alignment, scoliosis
Cerebral palsy - increased tone, abnormal running gait
Spine - spina bifida / scoliosis
Duchenne's muscular dystrophy / Gower's sign
- ask to squat then stand up
- have to hand walk up their legs as severe proximal muscle weakness
Ankle
- ankle ROM
- Silverskiold
Investigations
Spine: Xray / MRI
Gait analysis
EMG
Serum CPK - DMD > 5000
Nonoperative
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