Treatment of Toe Walking in Autism Spectrum Disorder
For children with ASD who present with toe walking, implement the "Cast and Go" protocol combining botulinum toxin injection with serial ankle casting followed by rehabilitative therapy, as this provides the most effective short-term correction of the gait pattern. 1
Initial Assessment and Differential Diagnosis
When evaluating toe walking in a child with ASD, measure the baseline ankle dorsiflexion angle, as this directly predicts the number of casts required for correction (with lower baseline angles requiring more casts). 1 Note that male patients typically present with higher baseline dorsiflexion angles than females. 1
Critical caveat: Toe walking in ASD should trigger a comprehensive developmental assessment beyond just the motor concern. Up to 77% of children presenting with idiopathic toe walking have receptive or expressive language delays, 40% have visuomotor delays, 33% have fine motor delays, and 27% have gross motor delays. 2 This means toe walking functions as a red flag for broader developmental issues requiring multidisciplinary evaluation. 2
Treatment Algorithm
First-Line Intervention: Cast and Go Protocol
The structured approach consists of three sequential components:
- Botulinum toxin injection into the gastrocnemius-soleus complex to reduce muscle tone 1
- Serial ankle casting to progressively stretch the Achilles tendon and maintain dorsiflexion 1, 3
- Rehabilitative therapy following cast removal to strengthen dorsiflexors and retrain gait patterns 1
This protocol demonstrates effectiveness without adverse events and achieves correction in the shortest acquisition time. 1 The evidence for casting in idiopathic toe walking is strong, though outcomes beyond 1 year are less certain without surgical intervention. 3
Important limitation: Adding botulinum toxin to casting does not provide superior outcomes compared to casting alone, but the combined protocol remains the recommended approach based on the most recent ASD-specific evidence. 1, 3
Alternative and Adjunctive Options
If the Cast and Go protocol is not feasible or fails:
- Ankle-foot orthoses (AFOs) restrict toe walking while worn but children immediately revert to equinus gait once removed, making this a temporizing rather than corrective measure. 3
- Physical therapy alone has limited evidence for long-term correction. 3
- Surgical lengthening of the gastrocnemius-soleus-Achilles complex provides the only treatment with documented long-term results beyond 1 year, reserved for severe contractures or failed conservative management. 3
Behavioral Considerations in ASD
Recognize that toe walking in ASD may represent more than biomechanical limitation—it can reflect sensory avoidance behavior (minimizing ground contact) or broader communication difficulties. 1, 4 The persistence of toe walking beyond typical developmental windows (prevalence is 41% in children with neuropsychiatric diagnoses versus 2% in typically developing 5.5-year-olds) suggests this is not purely idiopathic. 3
Assessment gap: Current evaluation methods are predominantly qualitative and heterogeneous, with no standardized quantitative assessment tool validated specifically for ASD populations. 4 Most studies assess toe walking only during ambulation, though children with ASD often also stand and run on tiptoes. 4
Monitoring and Follow-Up
Track ankle dorsiflexion angle serially to determine when adequate correction is achieved. 1 The number of casts required correlates inversely with baseline dorsiflexion, allowing prediction of treatment duration. 1
Critical warning: Persistent untreated toe walking leads to secondary Achilles tendon shortening and fixed equinus contracture, creating functional limitations and pain that significantly impact quality of life. 4, 5 Early intervention prevents these structural complications.
Integration with Comprehensive ASD Management
Since toe walking co-occurs with language delays in the majority of cases, coordinate treatment with speech-language pathology services. 2 Occupational therapy evaluation for sensory integration dysfunction and visuomotor delays should occur concurrently. 2 This aligns with broader ASD treatment principles emphasizing structured behavioral interventions and addressing comorbid developmental concerns. 6
The treatment decision should prioritize preventing long-term structural deformity and functional impairment (morbidity) while addressing the immediate gait abnormality, rather than viewing toe walking as merely a cosmetic concern. 3, 5