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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:

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).

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