Toe Walking Clinical Presentation

Updated: Apr 25, 2023
  • Author: Ryan Krochak, MD; Chief Editor: Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS  more...
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A child with idiopathic toe walking (ITW) typically presents as a toddler, without other significant medical history and with a normal developmental profile, especially a normal age for the commencement of walking (< 18 mo). Parents report that the child walks and runs on the toes of both lower extremities symmetrically, particularly when he or she is unaware of being observed. However, the child often can walk flatfooted if prompted.

The presentation of toe walking in a patient with a discrete central or peripheral nervous system etiology (non-ITW) differs from that of a patient with ITW. In a patient with cerebral palsy (CP), there is often a history of prematurity and of global developmental delay, especially a delayed age at which the child began walking. There may also be a history of a significant head injury or vascular event before age 2 years.

Other features upon presentation that may suggest non-ITW include the following:

  • History of spinal cord injury
  • Progressive loss of lower-extremity function
  • Asymmetric progressive lower-extremity deformity

Specific spinal cord lesions that can result in asymmetric toe walking include spinal cord tumor and split-cord malformation/diastematomyelia.

A patient with toe walking secondary to a degenerative muscle disease usually presents later (age range, 3-5 y), often after the primary diagnosis has been established. The developmental history or past medical history in this patient population is typically normal.

The differences in presentation between the various patient groups can be subtle and subject to overlap. Therefore, it is imperative that the examiner routinely review the child’s perinatal history, developmental history, and past medical history, as well as obtain a detailed history of present illness, so as to minimize the likelihood of missing a diagnosis with significant long-term medical implications for the patient.


Physical Examination

The examiner’s responsibility in evaluating a patient with toe walking is to rule out all defined etiologies before settling on a diagnosis of ITW.

The examination should begin with an overall assessment of patient appearance and gait. Gait can be observed as the patient moves about the room or walks down a hallway. (See the images below.) A focused examination of the spine and lower extremities is then required. The child’s lower extremities and spine should be inspected for cutaneous abnormalities, leg-length discrepancy, asymmetric or abnormal muscle development, pelvic asymmetry, and fixed-foot deformities.

Idiopathic toe walking in 10-year-old boy: rear an Idiopathic toe walking in 10-year-old boy: rear and side views.
Idiopathic toe walking in 10-year-old boy: closeup Idiopathic toe walking in 10-year-old boy: closeup view.

Although a thorough neurologic examination is challenging in this age group, muscle strength can be gauged by the ability of the child to rise independently from the floor and to climb the examination table. Reflexes, muscle tone, and withdrawal to stimuli are easier data points to acquire.

Assessment of range of motion (ROM) of the knee, hip, and ankle joints completes the examination. Ankle ROM should be assessed with the knee both flexed and extended (Silfverskiöld test). In addition, ankle dorsiflexion should be examined with the heel in neutral position; hindfoot valgus gives the false appearance of acceptable dorsiflexion.

For the patient with ITW, the examination is normal except for the symmetric presence of bilateral toe walking and a variable degree of heel-cord tightness. An asymmetric toe-walking profile essentially excludes the diagnosis of ITW and prompts further investigation.

Pomarino et al evaluated ITW pattern in 836 children, employing specific tests that had not previously been used by other researchers. [37] The children were analyzed over a period of 4 years. Questions regarding family history were recorded. Tests included ankle dorsiflexion, lumbar lordosis angle, clinical spin test, walking after spin test, and heel walking test, which revealed that in all cases, children with a positive family predisposition were significantly more affected than those with a negative family predisposition. This study was aimed at developing new tools for improved diagnosis of ITW.

In a patient with a central nervous system disorder (eg, CP), muscle spasticity is apparent at the time of the initial evaluation, and deep tendon reflexes are hyperactive. Gait evaluation suggests overall difficulty with coordination and balance, as well as different degrees of upper-extremity flexion posturing, depending on the extent of involvement. The anatomic distribution of the spasticity should be noted; this is correlated with the extent of the lesion of the motor cortex. In addition, the examiner should determine if the toe walking is secondary to Achilles tendon contracture or if it is a compensation for spastic knee and hip flexion.

In a patient with muscular dystrophy, the classic findings are lumbar lordosis, calf hypertrophy, and a positive Gowers sign (ie, the need to prop oneself up on the thighs with the arms in order to rise from a seated position on the floor). Strength examination suggests greater weakness of proximal hip and shoulder muscles.