Idiopathic Toe Walking

What is Idiopathic Toe Walking?

The term ‘Idiopathic Toe Walking’ means that the cause of the tip toe walking is not known. The condition can also be called ‘Habitual toe walking’ and ‘Congenital short Achilles tendon’. (The Achilles tendon is the strong band which joins the calf muscles to the heel bones. This enables us to lift our heels off the floor when we are standing and to point our toes down when sitting. )

Idiopathic toe walking results from a congenital shortness of the tendon (means shortness of the tendon ‘from birth’) or from a habit of toe walking that leads to a fixed contracture (permanent shortness) of the Achilles tendons. Young children who display tip toe walking invariably have both feet involved. Many can stand with their feet flat if prompted to do so although this usually causes them to turn their feet out sideways and stick their bottoms out. Without treatment, persistent shortening of the Achilles tendons can lead to other more serious foot deformities or episodes of pain in the heel and calf especially during periods of rapid growth.

There are other reasons for tip toe walking which do have a known cause. The diagnosis is made by thorough top-to-toe physical examination and by taking a good early birth and developmental history to rule out other more serious causes. This is most often done by a Children’s Physiotherapist who may refer on to an Orthopaedic Consultant for further investigations. Idiopathic toe walking first appears in a toddler as walking begins. Many children begin to walk on their toes. Some give up this apparent ‘habit’; others do not. Those who continue to do so may need assessment.

What treatments are available?

Treatment of toe walking includes observation, stretching, casting, and orthotics. It does not respond to nagging!

A toddler with idiopathic toe walking who has just begun to walk and who is without fixed contractures should simply be observed. For many toddlers and young children, this condition represents a temporary ‘habit’ pattern of walking. The child should be monitored at 3 - month intervals. If progressive Achilles tendon contractures are detected or if the walking pattern does not improve on its own by age 3 years, treatment should be considered.

In mild or early cases, special stretching techniques will be taught to the parents (carers) which need to be done on a daily basis. As the child becomes older and less happy to sit for stretches, they will be taught how to stretch themselves under supervision during play activities. If the problem is more severe and stretching has not helped, referral to an Orthopaedic Consultant may be suggested. They can recommend other forms of treatment such as:

Serial Casting:

The lower legs are set in plaster with the knees bent and ankles as close to a right angle (90º) as possible. When the child walks, they will maintain a good stretch on the Achilles tendons as the knee straightens. A pair of plaster boots will protect the base of the plaster and allow the child to walk more easily. The plasters are usually kept on for 1-2 weeks. The ankles and feet are then mobilized and the Achilles tendons stretched before the plasters are replaced for another 1-2 weeks. This process is generally repeated 3 times in total (6 weeks).

During this time, your child will be encouraged to do exercises to stretch other leg muscle groups and to strengthen their posture muscles. Once the plasters are removed, the muscles of the lower legs will be weak and have lost a lot of bulk (shape). This is normal but if you and your child are not prepared for it, can be quite a shock. Your child may find it difficult to walk for a short time (a day or so) or walk rather like ‘Charlie Chaplin’. It is during this critical time that the Physiotherapist will help re-educate the walking pattern of your child. Although this is a less invasive treatment option, older children who have walked in a tip toe fashion all their life or who have particularly tight Achilles tendons may not respond and go back to their old style of walking.

Orthotics:

Your child may be referred to a Podiatrist who can supply special ‘cosmetic’ splints or insoles to be worn with their usual footwear. The splints give a stretch during the waking hours and can be taken off for bathing and for sleeping at night.

Surgery:

In the event of the Achilles tendons remaining tight and resistant to other treatment methods, the Orthopaedic Surgeon may consider lengthening the tendons during a small operation. This is most often done through keyhole surgery these days. The lower legs are then set in plaster casts again for approximately 6 weeks after which, the physiotherapist will be involved in regaining movement, strength and re-educating a good walking pattern.

At Vale Healthcare, we have a team of children’s specialists available to assess and offer the most appropriate treatment options to meet the needs of your child and family. For more information please contact Liz Atter on 07722 147 502.