Toe walking is one of the most common reasons for a primary care evaluation of abnormal gait. Neurologic etiologies of toe walking are common and most concerning for both parents and their doctors. There may be clues in the patient's history or physical examination that can help the primary care provider in giving reassurance as well as determining the cause before referral. A toe walking pattern is thought to be a normal stage in development of gait, but should resolve by around 7 years of age. The prevalence of toe walking in normally developing children at age 5.5 years is 2% and 40% for children with developmental delays or neuropsychiatric diagnoses. There is a slight male predominance. Toe walking is most often idiopathic, however, this is a diagnosis of exclusion.
Determining the underlying etiology can sometimes be as easy as asking the appropriate questions when obtaining the history. Localizing the potential lesion is important to appropriate testing. Clues to etiology include birth and developmental history, age of onset when the toe walking was first noted (i.e. did it start as soon as they started walking or did it develop over time?) and family history. Studies show that there can be a family history of toe walking in 10-88% of idiopathic toe walkers. The most common causes and diagnoses associated with toe walking include: idiopathic, cerebral palsy, tethered spinal cord, muscular dystrophies, neuropathies (i.e Charcot Marie Tooth), brain or spinal cord injury, spina bifida, autism spectrum disorder or other sensory processing disorder and tendon or joint contractures. Performing a detailed physical examination is helpful. As a practical matter, the key is to identify treatable conditions first.
What are common causes of toe walking in children?
Common causes of primary toe walking include:
Acquired toe walking causes include:
What findings in the history or physical exam can be helpful to determine the cause of toe walking? (See table)
Physical examination signs that can be helpful include:
- Sacral dimple, hair tuft, or pigmentation – indicating possible underlying spinal cord or vertebral column abnormality
- Pseudohypertrophy of the calves – seen in muscular dystrophies
- Abnormal reflexes – can be brisk or diminished (brisk indicating upper motor neuron disorder, diminished suggesting neuropathic or lower motor neuron disorder)
- Abnormal tone
- Inability to put heels down when prompted in an individual who is old enough and can comprehend speech
- Foot drop
Examples of some causes with their associated history and physical exam findings:
If one or several of the signs above are found during a physical examination, a referral to visit the neurologist is recommended. If not pursued prior to the visit, diagnostic evaluations may include: MRI brain and/or spine, CK, or EMG/NCS. Treatment options include physical therapy, orthotics, serial casting, chemical denervation and surgical intervention depending on etiology and severity.