eMedicine Specialties > Orthopedic Surgery > Foot & Ankle

Toe Walking: Treatment

Author: Edwards P Schwentker, MD, Professor, Departments of Orthopedics and Rehabilitation and Pediatrics, Pennsylvania State College of Medicine
Contributor Information and Disclosures

Updated: Jan 22, 2009

Treatment

Medical Therapy

Nonoperative treatment of toe walking includes observation, stretching, casting, and orthotics. A toddler with idiopathic toe walking who has just begun to walk and who is without fixed contractures should simply be observed. For many patients, this condition represents a temporary habit pattern. The patient should be monitored at 6-month intervals. If progressive heel-cord contractures are detected or if the pattern does not resolve spontaneously by age 3 years, treatment should be considered.

Stretching of the Achilles tendon in idiopathic toe walking offers a limited chance of success, but it may be politic to begin with this modality when parents initially are reluctant to accept more invasive treatment. For any chance of success, however, stretching must employ the patient's own body weight. Even in a child, these lower extremity muscles are too powerful to allow effective stretch by parents or therapists with simple passive dorsiflexion. The parents should be taught to help the child stretch by having the child stand with the forefoot elevated on a small block so that the heel may drop downward. The parents steady the child and add gentle pressure to the stretching process.

In a second technique, the patient leans forward against a counter, with feet together and pointed straight forward, knees straight, and hips extended. Again, the parents assist by steadying the child and adding gentle pressure. Progressive stretch is accomplished by increasing the distance from the counter. It should be stressed to the parents that they must be involved. Even older children do not perform such exercises effectively if unassisted.

Serial casting is an effective technique for gaining stretch of the Achilles tendon.^5,6 The child should be placed in a below-the-knee plaster or fiberglass cast while the knee is flexed. This is accomplished most easily with the child prone and the knee bent while an assistant pushes gently downward on the forefoot. Once the cast has set, the gastrocnemius component will stretch further as the knee extends. These casts should be changed weekly to progressively increase the range of dorsiflexion. Between cast changes, the child can walk fairly effectively with cast boots.

The author's preferred method of nonoperative treatment for idiopathic toe walking employs an articulated molded ankle-foot orthosis (MAFO) (see Image 1). This appliance is cosmetically acceptable, fits in a regular shoe, allows nearly normal ambulation, and prevents plantarflexion while allowing full dorsiflexion. With an articulated MAFO, the heel cord is stretched with every step. These devices are worn during all waking hours for a minimum of 6 months. MAFOs must be custom fabricated and, hence, cost several hundred dollars apiece, but they can be expected to fit for 12-18 months. Often, the toe walking habit pattern disappears after MAFOs have been worn for this length of time.

For toe walking that is secondary to muscle spasticity, stretching alone invariably is ineffective. Serial casting can be used to lengthen the Achilles tendon, but the contracture will recur rapidly unless the patient is maintained in an MAFO. An articulated MAFO is an effective appliance for preventing the progressive spastic equinus that occurs with growth, providing it is applied consistently. If a patient with spasticity continues to toe walk when MAFOs are discontinued after the patient reaches skeletal maturity, operative lengthening may then be considered so that the orthosis can be discontinued. After skeletal maturity, equinus in a patient who is spastic is less likely to progress.

For toe walking associated with paralytic muscle disease, the use of regular stretching and orthoses together should be considered. Both modalities of nonoperative treatment are preferable to operative lengthening, as the latter must weaken the muscle. Prolonged use of serial casts also weakens muscles and should be avoided.

Nonoperative treatment of toe walking includes observation, stretching, casting, and orthotics. A toddler with idiopathic toe walking who has just begun to walk and who is without fixed contractures should simply be observed. For many patients, this condition represents a temporary habit pattern. The patient should be monitored at 6-month intervals. If progressive heel-cord contractures are detected or if the pattern does not resolve spontaneously by age 3 years, treatment should be considered.

Stretching of the Achilles tendon in idiopathic toe walking offers a limited chance of success, but it may be politic to begin with this modality when parents initially are reluctant to accept more invasive treatment. For any chance of success, however, stretching must employ the patient's own body weight. Even in a child, these lower extremity muscles are too powerful to allow effective stretch by parents or therapists with simple passive dorsiflexion. The parents should be taught to help the child stretch by having the child stand with the forefoot elevated on a small block so that the heel may drop downward. The parents steady the child and add gentle pressure to the stretching process.

In a second technique, the patient leans forward against a counter, with feet together and pointed straight forward, knees straight, and hips extended. Again, the parents assist by steadying the child and adding gentle pressure. Progressive stretch is accomplished by increasing the distance from the counter. It should be stressed to the parents that they must be involved. Even older children do not perform such exercises effectively if unassisted.

Serial casting is an effective technique for gaining stretch of the Achilles tendon.^5,6 The child should be placed in a below-the-knee plaster or fiberglass cast while the knee is flexed. This is accomplished most easily with the child prone and the knee bent while an assistant pushes gently downward on the forefoot. Once the cast has set, the gastrocnemius component will stretch further as the knee extends. These casts should be changed weekly to progressively increase the range of dorsiflexion. Between cast changes, the child can walk fairly effectively with cast boots.

The author's preferred method of nonoperative treatment for idiopathic toe walking employs an articulated molded ankle-foot orthosis (MAFO) (see Image 1). This appliance is cosmetically acceptable, fits in a regular shoe, allows nearly normal ambulation, and prevents plantarflexion while allowing full dorsiflexion. With an articulated MAFO, the heel cord is stretched with every step. These devices are worn during all waking hours for a minimum of 6 months. MAFOs must be custom fabricated and, hence, cost several hundred dollars apiece, but they can be expected to fit for 12-18 months. Often, the toe walking habit pattern disappears after MAFOs have been worn for this length of time.

For toe walking that is secondary to muscle spasticity, stretching alone invariably is ineffective. Serial casting can be used to lengthen the Achilles tendon, but the contracture will recur rapidly unless the patient is maintained in an MAFO. An articulated MAFO is an effective appliance for preventing the progressive spastic equinus that occurs with growth, providing it is applied consistently. If a patient with spasticity continues to toe walk when MAFOs are discontinued after the patient reaches skeletal maturity, operative lengthening may then be considered so that the orthosis can be discontinued. After skeletal maturity, equinus in a patient who is spastic is less likely to progress.

For toe walking associated with paralytic muscle disease, the use of regular stretching and orthoses together should be considered. Both modalities of nonoperative treatment are preferable to operative lengthening, as the latter must weaken the muscle. Prolonged use of serial casts also weakens muscles and should be avoided.

Surgical Therapy

If conservative measures fail to correct idiopathic toe walking after about 12 months, consider operative lengthening. This procedure can be performed under a brief anesthetic by either an open or percutaneous technique.^7,8

Perform an open heel-cord lengthening through a medial incision 6-8 cm in length, stopping distally just proximal to the tendon's insertion into the calcaneus. Avoid a straight posterior approach, because the skin scar may contract and limit dorsiflexion. Open the sheath and incise the tendon longitudinally over the full length of the exposure, dividing the tendon into 2 equal halves. Detach one half proximally and the other distally in a Z fashion. Allow the tendon to lengthen to the degree desired, and suture the 2 halves back together in the lengthened state. Follow this repair with a standard skin closure, and immobilize the patient in a below-the-knee walking cast for 6 weeks.

The author prefers a percutaneous lengthening of the Achilles tendon for most patients with idiopathic toe walking. To perform this technique, have an assistant hold the patient's foot and ankle in maximum dorsiflexion after the skin is prepared. A thin-bladed tenotomy knife is inserted through a small medial stab wound 5-8 cm above the calcaneal insertion, depending on the size of the patient. By feel, divide the medial half of the proximal tendon.

Make a second medial stab wound just above the distal insertion, and there, divide the anterior half of the tendon. If the tendon has rotated a full 90º over this length, half of the fibers will have been cut proximally and the other half will have been cut distally. The assistant will feel the tendon give, and the equinus contracture may then be corrected. After covering the wounds with small dressings, apply the below-the-knee cast. Control the amount of correction by immobilizing the foot and ankle in the cast in more or less dorsiflexion.

If the tendon fails to part with 2 incisions, make a third stab wound from straight posterior, halfway between the first 2 incisions. Through this, cut the lateral half of the fibers until the tendon gives.

Open and percutaneous techniques are applicable to patients with toe walking secondary to muscle spasticity. As indicated, however, before simply lengthening the Achilles tendon in a patient with spasticity, it is critical to determine whether a component of the toe walking is caused by spastic flexion of the knee and possibly also of the hip. Observe the patient in gait. Is the ankle truly in equinus, or is the patient bearing weight on the forefoot because the knee is flexed? If the latter is true, do not lengthen the heel cord. Doing so will change a jumper's gait into a crouch gait and worsen the patient's ability to walk. To treat such a patient appropriately, consider lengthening the hamstrings and possibly the hip flexors. Management of this complex multiple-joint situation is beyond the scope of this article.

Patients with spasticity with unilateral involvement, or spastic hemiplegia, usually have true equinus. If the patient walks with the knee no more than slightly flexed and the ankle is in definite plantarflexion, the heel cord may safely be lengthened. If the ankle can be brought passively to neutral with the knee flexed, but the ankle thrusts into equinus as the knee is extended, consider release of the gastrocnemius insertion alone. This release is performed through the gastrocnemius aponeurosis just before it joins the aponeurosis of the soleus to form the Achilles tendon proper. If the ankle remains in significant equinus despite knee flexion, lengthen the entire tendon as described above, either with an open Z technique or percutaneously.

Heel cord lengthening can be considered in a patient with paralytic muscle disease who walks on the toes, but only if the knee extends fully and the quadriceps muscle has normal or near-normal strength. If the patient is using toe walking to generate an extension moment at the knee to compensate for a weak quadriceps, lengthening the heel cord will cause a premature loss of ambulation. All patients with Duchenne muscular dystrophy during their last few years of ambulation employ toe walking to compensate for weak knee extensors. Management of toe walking in such patients must be confined to nonoperative modalities.

Postoperative Details

After a heel cord has been lengthened with either an open or a percutaneous technique, the patient should be immobilized in a below-the-knee walking cast for 6 weeks. The position of the ankle is critical if the operation was performed percutaneously, because the position determines the degree to which the tendon is lengthened. The ankle should be placed in more dorsiflexion to increase length, and in more plantarflexion to minimize lengthening.

Follow-up

Following cast removal, the patient may resume walking as tolerated. A patient with idiopathic toe walking will be unable to toe walk and will run flatfooted immediately out of casts. Warn the parents preoperatively that this weakness is to be expected. The gastrocnemius and the soleus will regain strength slowly over the subsequent few months, and the ability to toe walk and to run usually will return.⁹ Monitor the patient for at least 6 months after these abilities are regained to ensure that toe walking does not recur. If it recurs, place the patient in articulated MAFOs.

Immature patients with spasticity or paralytic muscle disease should be monitored closely after heel cord lengthening. With growth or continued muscle fibrosis, contractures are prone to recur. Prescribe stretching and/or orthotics as needed to prevent recurrence.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center. Also, see eMedicine's patient education article Cast Care.

Complications

The chief concern following operative heel cord lengthening for a patient with idiopathic toe walking is recurrence. This is a rare complication, but if it occurs, the author recommends using an articulated MAFO for up to a year before considering repeat operative lengthening. The diagnostic workup should be repeated for any patient whose contractures have recurred as a means of looking for signs of neuromuscular disease or intraspinal pathology that might not have initially been evident.

Recurrence following operative heel cord lengthening also is possible in patients with spastic or paralytic muscle disease. The appropriate application of orthotics should prevent this complication in most cases.

A more serious complication for patients with toe walking secondary to spasticity or paralytic muscle disease is postoperative deterioration or loss of ambulation. Such complications can be avoided by careful preoperative evaluation of the appropriateness of heel-cord lengthening. If function is adversely impacted by tendon lengthening, the foot and ankle should be supported with an orthosis.

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