Tip-Toe Walking

Tip-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 neuromuscular and developmental assessment is needed as tip-toe walking can be associated with:

• Developmental delay (need to assess speech, language, hearing, communication).
• 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 medication 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). This 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? Is there regression of achieved milestones?
• Has there been a change in mood or behaviour?
• Is the child clumsy? (is there a tendency to fall over?)

Assessment should include:

• 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 positive Gower’s test. In cerebral palsy there can be a diplegiac or hemiplegia gait with upper extremity flexion posturing.
• Check muscle bulk - calf muscle (pseudo) hypertrophy or wasting may suggest muscle or joint disease.
• Look for Achilles tendon contracture (can suggest muscle disease or neurological disease). Check that the foot dorsiflexes to more than 90 degrees (usually 95-100 degrees) but must be symmetrical.
• Neurological examination (tone, reflexes, power).
• Ask the child to stand, from sitting on the floor or squat, without using their hands (if unable to do this, then it may suggest muscle disease).
• Ask the child to squat, or stand, with their heels on the floor (if unable to do this, then it may suggest tight Achilles).
• Assess Gower manoeuvre.
• Shoes - look for excessive / asymmetrical wear and tear of the sole.

Indications for referral (to general paediatrics / paediatric orthopaedics usually):

• Asymmetrical tip-toeing.
• Delay or regression of milestones.
• Persistent problems over 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 a change from a previous gait pattern).
• 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 (proximal weakness).

                        Squat or stand with their heels on the floor (Achilles tightness).

                        Jump (should be achieved by school-age child).