Tip-Toe Walking

Tip-toe walking (or simply toe-walking) is common in healthy young children, and should resolve spontaneously by 3 years of age. Sometimes, however, toe-walking may be pathological and careful joint, neuromuscular and developmental assessment is always necessary as toe-walking can associate with:

• Developmental delay (need to assess speech, language, hearing, communication). Toe-walking gait can also be seen in children with Autism Spectrum Disorder (ASD).
• Neurological disease (consider Muscular Dystrophy, Cerebral Palsy).
• Inflammatory problems (consider Arthritis, Inflammatory Muscle Disease) resulting in a short Achilles tendon.
• Metabolic conditions (consider Mucopolysaccharidoses).
• Congenital abnormalities (consider Clubfoot, Developmental Dysplasia of the hip which can cause leg length discrepancy).

Management depends on the underlying cause - physiotherapy, sometimes medications can help (e.g., botulinum injections), and rarely surgery are required.

A careful history and neuromuscular, joint and developmental assessments are needed.

Key questions include:

• Does the child have pain in their feet or legs?
• Is there any morning stiffness or 'gelling' (a sensation of stiffness after periods of inactivity such as sitting cross-legged on the floor or after long car journeys)? Gelling can be a feature of inflammatory arthritis.
• Are there any functional problems (e.g., speech, hearing, feeding, or difficulties taking part in sport or play)?
• Assess motor development; is there a delay in motor milestones, or regression of achieved milestones?
• Has there been a change in mood or behaviour?
• Is the child clumsy (e.g., is there a tendency to fall over)?

Assessment should include the following:

• pGALS to assess all joints and pREMS for a detailed joint examination as necessary. 
• Assess gait – in muscular dystrophy tip-toeing is accompanied by an exaggerated lumbar lordosis, calf hypertrophy and a positive Gower’s test. In cerebral palsy there can be a diplegic or hemiplegic gait with upper extremity flexion posturing.
• Check muscle bulk - calf muscle (pseudo-) hypertrophy or wasting may suggest muscle or joint disease.
• Assess Achilles tendon for contracture (this can suggest muscle disease or neurological disease). Do this by checking that the foot dorsiflexes to more than 90 degrees (usually 95-100 degrees) and that both feet are symmetrical.
• Complete a neurological examination (tone, reflexes, power).
• Ask the child to stand, from sitting on the floor or squatting, without using their hands (if unable to do this, then it may suggest muscle disease - look for Gower's sign). A child who must use their hands to get up off the floor, usually by pushing against their own body (or walking-up their own body) is said to have a positive Gower test, or be demonstrating Gower’s sign.
• Ask the child to squat, or stand while their heels are on the floor (if they unable to do this, then it may suggest tight Achilles tendons).
• Examine the patient's shoes - look for excessive / asymmetrical wear and tear of the sole.

Indications for referral (general paediatrics / paediatric orthopaedics / paediatric neurology):

• Asymmetrical tip-toe walking.
• Delay or regression of milestones.
• Persistence beyond the age of 3 years.
• Suspicion of joint or muscle disease (e.g., pain, swelling, stiffness, clumsiness, weakness; this may be suggested if toe-walking is new and a change from a previous gait pattern).
• 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 (suggests proximal weakness).
• Squat or stand with their heels on the floor (suggests Achilles tendon tightness).
• Jump on both feet (should be achieved by school age child).