What is the appropriate management approach for a child with toe walking, considering factors such as age and potential underlying medical conditions like cerebral palsy?

Approach to Toe Walking in Children

Toe walking in children requires a systematic evaluation to differentiate idiopathic toe walking from serious underlying neuromuscular or anatomical disorders, with management based on age, severity of contracture, and underlying etiology. 1, 2

Initial Assessment

History and Physical Examination

Essential historical features to elicit:

• Age of onset and duration of toe walking (abnormal if persisting past age 2 years) 2
• Unilateral versus bilateral presentation (asymmetric gait is a red flag requiring urgent evaluation) 3
• Regression of previously acquired motor skills (necessitates immediate workup) 3
• Developmental history, including presence of autism or other neuropsychiatric diagnoses (41% prevalence in children with neuropsychiatric conditions versus 2% in typically developing children at age 5.5 years) 1
• Family history of toe walking 1
• Pain or functional limitations versus purely cosmetic concerns 1

Critical physical examination components:

• Passive ankle dorsiflexion range of motion with knee extended and flexed (to assess gastrocnemius versus soleus contracture) 1
• Neurological examination including tone, reflexes, strength, and sensation 2
• Observation for hand asymmetry or other signs of hemiplegia 4
• Assessment for signs of cerebral palsy, particularly mild spastic diplegia 2
• Evaluation for Duchenne muscular dystrophy (calf pseudohypertrophy, Gowers sign) 2
• Gait analysis to identify compensatory patterns 5

Differential Diagnosis Algorithm

Red Flags Requiring Urgent Referral

Immediate pediatric neurology referral indicated for: 3

• Abnormal neurological examination findings
• Unilateral toe walking or asymmetric gait
• Regression of motor milestones
• Associated weakness, spasticity, or hyperreflexia

Common Etiologies to Exclude

Neuromuscular conditions: 2

• Cerebral palsy (especially mild spastic diplegia—can be difficult to differentiate from idiopathic toe walking)
• Duchenne muscular dystrophy
• Other myopathic or neuropathic disorders

Anatomical causes: 2

• Congenital Achilles tendon contracture
• Limb length discrepancy

Associated conditions: 1, 2

• Autism spectrum disorder
• Other developmental disorders

Idiopathic toe walking is a diagnosis of exclusion after ruling out the above conditions through history and physical examination. 2, 6

Management Based on Severity and Age

Observation

Appropriate for: 2, 6

• Children under age 2 years with normal neurological examination
• Mild cases without functional impairment or contracture
• Full passive ankle dorsiflexion maintained

Conservative Treatment

Serial casting indicated for: 1

• Children with moderate contracture
• Good evidence for effectiveness in idiopathic toe walking
• Does not provide long-term results beyond 1 year as monotherapy

Ankle-foot orthoses (AFO): 1, 7

• Restrict toe walking when worn
• Children typically revert to equinus gait once orthosis removed
• May be appropriate for mild gait abnormality management during evaluation
• Help maintain mobility and prevent secondary complications 3

Botulinum toxin with casting: 1

• Does not provide better outcomes compared with casting alone
• Not recommended as first-line treatment

Physical therapy and gait training: 8

• May increase range of external hip rotation
• Verbal reinforcement for mild cases 6

Surgical Intervention

Gastrocnemius-soleus-Achilles complex lengthening indicated for: 1, 2

• Severe Achilles tendon contracture
• Persistent toe walking despite conservative treatment
• Only treatment providing long-term results beyond 1 year 1
• Favorable prognosis with normal function and plantarflexion range achieved 2

Pediatric orthopedic referral appropriate when: 3

• Gait abnormality requires orthotic management
• Surgical intervention being considered
• Associated limb deformities suggesting skeletal dysplasia 9

Age-Specific Considerations

Infants and toddlers (under 18 months): 8

• Simple brace treatment if medial foot deviation exceeds 10 degrees from mid-sagittal plane
• Early intervention prevents fixed deformity

Children 18 months to 2 years: 2, 6

• Observation appropriate if neurological examination normal
• Toe walking considered part of normal developmental spectrum up to age 2

Children over 2 years: 2, 6

• Persistent toe walking is abnormal
• Requires evaluation to exclude underlying pathology
• Treatment decisions based on contracture severity and functional impact

School-age children (over 5-7 years): 1, 8

• Internal tibial or talar torsion usually resolves by age 7
• Femoral torsion becomes fixed by age 8 if untreated
• Surgical intervention more likely needed for persistent cases

Common Pitfalls

• Failing to recognize unilateral toe walking as a red flag requiring urgent neurological evaluation rather than benign observation 3
• Difficulty differentiating mild cerebral palsy from idiopathic toe walking—maintain high index of suspicion and low threshold for neurology referral 2
• Delaying treatment in young children—deformities become fixed and irreversible if untreated during critical developmental periods 8
• Over-relying on AFOs—children revert to toe walking once removed, limiting long-term effectiveness 1