Toe walking in children – Symptoms,Causes and Management
Walking (Gait) is a complex activity which a child learns from the very early years of development and needs an intact central and peripheral nervous system. As a Consultant Pediatric Neurologist, I often come across questions from parents with regards to ambulation e.g. “My child is very clumsy”, “My child is tip-toe walking”, “My Child does not walk fast”, “My child tends to fall easily” etc.
Gait and functional ambulation are important markers of disease and disability in childhood. Gait velocity (Walking speed) is the 6th vital sign of human function and is a predictor of overall health and disability. Walking in children is a complex activity and “speed” alone does not reflect all contributing factors and influences on the child’s gait. Children with gait abnormalities can have limitations which include difficulty walking longer distances; problems with balance, low walking confidence or fear of falling, decreased participation opportunities in school and community etc. Therefore, whenever a child comes with gait abnormality a careful clinical history and complete Neurological examination is carried out by a trained Pediatric Neurologist.
“Tip-Toe”/ “Toe” walking is one of the most common gait abnormalities I come across in my practice. Toe walking is the inability to generate a heel strike during the initial contact phase of the gait cycle, the absence of full foot contact during the entire standing phase. Classically the child stands or walks on his/her forefoot and is a common pattern seen in healthy developing children less than 2-3 years old. In most cases Toe walking spontaneously resolves before 2-3 years of age and do not need any intervention. In this blog, I will discuss some of the most common neurological causes of prolonged toe-walking and the need for early diagnosis and management in these children.
1. Idiopathic Toe walking:
Idiopathic Toe Walking (ITW), also known as Habitual Toe walking, is present in children older than 3 years of age still walking on their toes without signs of any neurological, orthopaedic or psychiatric diseases. ITW has been estimated to occur in 7% to 24% of the childhood population. The neurological examination in these children is usually normal apart from Toe walking and sometimes tightness around their ankles, also known as Tendo-Achilles (TA’s). Various investigations carried out in the clinic to look for underlying Neurological or Muscular disorders usually turn out to be normal.
2. Neurological and Neuromuscular Conditions:
There are numerous neurological conditions which can give rise to toe walking, the most common being Cerebral palsy. Classically seen in children who were born extreme prematurely, and the MRI brain scan in this group of children usually shows abnormalities leading to disrupted messages to the muscles which in turn leads to spasticity (tightness in muscles). The other reasonably common condition encountered is Duchene Muscular dystrophy which is a genetic muscle disorder usually seen in boys who present with delay in their motor milestones (delayed walking, toe walking etc) along with (sometimes) speech delay, or mild intellectual disability. Rarely, other Neurogenetic and Neurometabolic disorders can also present with toe walking. This group of disorders need early diagnosis and specialist intervention.
3. Neuro-developmental/Neurobehavioral disorders:
Toe walking can also be present in children with Autism, in children with communication (language) disorders and learning disabilities, as well as in children with fine motor, visuomotor- and gross motor delays without any tightness in their TA’s. It is thought to be due to acute sensory sensitivity to tactile stimulation. There are also issues with joint position so the child feels “disconnected” to own limb sand how to move in space. Once again investigations to look for underlying neurological disorders are usually normal.
The management of toe walking includes early diagnosis by a trained Pediatric Neurologist. The treatment modality depends on the diagnosis achieved after carrying out battery of tests. The main stay of treatment remains regular Physiotherapy. This includes active/passive stretches and visiting your pediatric Physiotherapist 2-3 times a week depending on the severity of “tight muscles”. Your child may also need Splints or Braces to keep the muscles and tendons stretched for prolonged periods.
The children, particularly with Autistic Spectrum Disorder and toe walking, need to see a trained Pediatric Occupational therapist. They benefit from massages to help “desensitize” the feet, proprioceptive exercises e.g. jumping on Trampoline, sensory modulation e.g. walking on sand or pebbles etc.
In some cases the doctor may have to start muscle relaxant medication called Baclofen, and occasionally Botulinum toxin (Botox) injections to the muscles. In severe cases surgical procedures are undertaken to “lengthen” the tendons carried out by specialist Pediatric Orthopedics surgeons. Early diagnosis and intervention is paramount to prevent long term disability.
Indications for referral to Pediatric Neurologist without delay:
- Asymmetrical tip-toe walking i.e. only on one side
- Delay or regression of milestones.
- Persistence at the age of 3 years.
- Suspicion of Neuromuscular Disease (e.g., stiffness, clumsiness, weakness etc).
- Suspicion of autism spectrum disorder.
- Family history of muscle disease.
- Children over the age of 3 years who are unable to:
- Stand from sitting on the floor without using hands.
- Squat or stand with their heels on the floor.
- Jump on both feet.
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