Children Tip Toeing

Normal Gait (walking)

A normal gait is called a heel-toe gait and that means that as one leg swings forward, it lands with the heel on the ground first. Then the body proceeds over that stance phase limb and finally the foot rises up on tip-toe right before it swings forward again. When the leg is on tip-toe, the other leg is on heel strike so in normal gait there is never a time when a child should be on both tip toes.

Walking On Tip Toes on One Side

One of the more common reasons is that one leg is quite short and if the leg is more than about 3 cm short, a child will often compensate by tip toeing so that the leg reaches the ground. A child that is spastic in one leg or one side of the body may tend to tip toe on that side because of the overactive Gastrocnemeus (calf muscle). A patient who has severe Achilles Tendonitis (pain in the back of the calf muscle) or severe Calcaneal Apophysitis (heel pain) might tip toe to take some of the tension off their Achilles tendon. A rarer cause of a child tip toeing on one side only could be a deep muscular calf Hemangioma. This is a vascular neoplasm which causes swelling of the calf muscle.

Walking On Both Tip Toes

The most common cause is idiopathic toe walking (no known cause), also called habitual toe walking. Walking on tip toes is quite common between 10 and 18 months when children are learning to walk. In some children it simply becomes a habit, when asked to walk normally they put their heel down on the ground before their toes. It's just that when they're not concentrating they seem to revert to walking on their toes.

Mild Spastic Diplegic Cerebral Palsy is also very common. The rarer conditions that can cause children to walk on both tip toes are Charcot-Marie-Tooth peripheral neuropathy or muscular dystrophy, such as Duchene. There are some less common things like autism, schizophrenia and finally spinal cord anomalies and juvenile type multiple sclerosis too.

Early onset tip toeing is defined as tip toeing that occurs within three months of the child walking. Far and away the two most common reasons for this are idiopathic toe walking and Spastic Diplegic Cerebral Palsy. Cerebral Palsy refers to a group of conditions that affect control of movement and posture. As of damage to one or more parts of the brain that control movement, an affected child cannot move his or her muscles normally. While symptoms range from mild to severe, the condition does not get worse as the child gets older. With treatment, most children can significantly improve their abilities.

Late onset tip-toe gait is defined as tip toeing which begins at least about four months after a patient has had a well-developed normal heel-toe walk. This is virtually always due to some neuromuscular problem which will require an examination by a neurologist.

It is also important to note if there was a family incidence of tip toe walking. One of the most common contributing factors is a tight Achilles tendon. Normally, a child should have about 10 degrees of ankle dorsiflexion (the amount your foot can extend towards your body when the foot is not tensed). However; a child can walk with a normal heel-toe gait as long as they can get to this neutral (The subtalar joint in the ankle is neutral when it is neither twisted in nor twisted out).

Treatment

Most children will need to be referred to a physiotherapist, orthopaedist and neurologist for treatment.

Idiopathic toe walking may be cured by just observing the condition and hoping that the child might eventually outgrow their tip toe gait. If you want to control an overactive calf muscle then the doctors might try to just hold it still with an ankle-foot orthosis (AFO Brace). If it is being caused by a tight Achilles tendon then surgery may be required. The most common procedure is a Gastrocnemius recession procedure. An alternative could be casting to correct the Achilles tendon.

It can be very difficult to distinguish between idiopathic toe walking and mild Spastic Diplegic Cerebral Palsy. It seems simple enough, but it really is not because both conditions are highly associated with premature birth, developmental delay and tight Achilles tendons. However, a good sign is if the child can walk completely normal when you ask them to, then it is more likely that they might have idiopathic toe walking.

For psychiatric toe walking, there is just no literature about how to treat this. There is very little literature about it at all. It's seen once in a while in schizophrenic children, autistic children or children with learning disorders. There are no relevant treatment options that have been documented for this.

Spastic Diplegic Cerebral Palsy is again almost always early onset to tip toeing. The family history is negative and they should have upper motor neuron lesions or dynamic EMG (Electromyography is a test that assesses the health of the muscles and the nerves controlling the muscles) that is abnormal. If there is an over active Achilles tendon then you could use bracing. If a patient’s dynamic contracture is so strong that they are fighting the brace, then the doctors might try casting or Botox (Botox is an experimental treatment) to weaken the muscle and then continue with the brace. If the Achilles is physically tight, then a lengthening procedure would be used and perhaps also hamstring lengthening if the patient is crouching significantly.

Signs of upper motor neuron lesions include weakness, hyperreflexia (Reaction of the autonomic (involuntary) nervous system to over-stimulation), and increased muscle tone. Note that with acute upper motor neuron lesions there is often flaccid paralysis (weakness or loss of muscle tone resulting from injury or disease of the nerves innervating the muscles) with decreased muscle tone and decreased reflexes.

Most children will eventually outgrow their tip toe gait but if you have any doubts then you should visit your family doctor as the first point of call.