The patient is a 4-year-old boy who comes to the clinic with maternal concerns for toe walking. This child started walking at 13 months of age, and around that time was noted to walk on his tiptoes. This was "cute" at first but persisted. He now walks "95% of the time" on his tiptoes. This child has otherwise normal growth and development and is doing well. No pain concerns and no limp. He does not fall excessively and can walk flat-footed if Mom tells him to. Investigation of his gestational, medical and family history reveals a child in good health with normal birth history, no prematurity and normal development.
Physical exam shows a healthy-appearing child with height and weight both at the 75th percentile. He is happy, active and playing. When he walks or runs he is on his tiptoes symmetrically. His heel cords are tight with passive dorsiflexion to 5 degrees with knees bent, and with knees in extension there is 5 degrees of persistent plantarflexion. The hip and knee exam are normal. His spine is without abnormality, and his neurological exam is nonfocal. Special tests show a negative Gower's sign and no velocity-dependent tone or spasticity at the ankles.
Discussion and Differential
The Silferskiold test checks passive ankle dorsiflexion in knee flexion and extension. A normal test shows >10 degrees dorsiflexion with knee extension and >20 degrees with knee flexion. (Figure 1)
Heel walking or heel stance in a child with normal heel cord flexibility. Child dorsiflexes easily beyond neutral. (Figure 2a)
In heel cord contracture, the child will hyperextend at the knees and flex hips in an attempt to dorsiflex ankles (simulated photo). (Figure 2b)
Gower's sign: Children with proximal muscle weakness will be unable to rise from the floor without using hands to "walk up" their body. This is classically seen in muscular dystrophy. (Figure 3)
Toe walking has a diverse but discrete differential diagnosis as described below. Clinical decision-making can be guided, in most cases, by a thorough history and careful physical exam.
Behavioral toe walking
Children with this diagnosis will not have tight heel cords on testing (see Figure 1) and can walk flat-footed on command. They can even "heel walk" (walk with toes elevated and ankles in dorsiflexion) when prompted (see Figure 2). Behavioral toe walking is more a preference for the child than a disease. This condition usually resolves on its own over time, and treatment is focused on parental education and reassurance. Behavioral toe walking is seen more frequently in children with developmental abnormalities such as autism.
Toe walking in children with cerebral palsy (CP) can be unilateral (hemiplegia) or bilateral (diplegia). While often associated with a history of perinatal brain injury/infection, prematurity or anoxia, CP can occur with a normal birth history. Exam shows spasticity or velocity-dependent tone (initial tightness, or "catch," then improved dorsiflexion when gentle constant pressure is applied). Clonus can sometimes be elicited when checking the heel cords. Rapid movements are more difficult, and running will often produce upper-extremity posturing and more pronounced toe walking. Referral to neurology is indicated to confirm this diagnosis.
Early in this condition, weakness of the hip muscles (proximal muscle weakness) but retained calf and distal strength result in toe walking. Children who toe walk due to this progressive condition often start out with a flat-footed gait and progress to toe walking at age 3 to 6 years. Gower's sign (see Figure 3) is seen in children with muscular dystrophy, and calf pseudohypertrophy can also be present on exam. The Duchenne form of muscular dystrophy is x-linked recessive and seen almost exclusively in males. Screening laboratory studies (such as an elevated creatine kinase) can strongly suggest the diagnosis. Definitive diagnosis is made through gene testing (dystrophin gene), electromyograph (EMG) and sometimes muscle biopsy.
Heel cord contracture
Exam shows decreased passive dorsiflexion of the ankles and is nearly always bilateral. Children with toe walking due to isolated heel cord contractures are healthy and have an otherwise normal history and exam. Because there is no specific cause for the heel cord contracture, this is sometimes referred to as "idiopathic" toe walking and is a diagnosis of exclusion. Treatment often involves an initial trial of physical therapy to teach heel cord stretching. Serial casting to stretch the Achilles tendons followed by night splinting may be successful, although this approach has a significant recurrence rate. Surgical lengthening of the heel cords after the age of 5 years has a high success rate.
This child had isolated heel cord contracture ("idiopathic toe walking").
This child was sent to physical therapy for Achilles tendon stretching with scheduled follow-up in two to three months. The family returned one year later. The patient went through six months of therapy with no improvement. The therapists also tried a trial of nighttime splinting. Despite these interventions, the patient had persistent heel cord contracture and toe walking with minimal improvement in passive ankle dorsiflexion. He was now developing pain at calves and plantar aspect of the foot with activity. Mom decided to opt for surgery, and the patient is scheduled for heel cord lengthening later this month.
- Sala, DA et al. Idiopathic toe-walking: a review. Developmental Medicine and Child Neurology 1999, 41: 846-48.
- Fox A, Deakin S, Pettigrew G, Paton R. Serial casting in the treatment of idiopathic toe-walkers and a review of the literature. Acta Orthopedica Belg 2006 Dec; 72(6): 722-30.
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