Toe Walking Treatment & Management

The management of toe walking is controversial; the natural history is poorly defined, and only limited data are available regarding direct comparisons of different treatment modalities. Therefore, the physician’s first decision point is whether the toe-walking gait should be treated at all or whether simple observation should be recommended.

Observation is appropriate for a toddler with idiopathic toe walking (ITW) who has recently begun to walk and is without fixed contractures. In many children, this condition is only a temporary habit, and a normal heel-toe gait eventually develops. ^{[2, 3]}

The patient should be monitored at 6- to 12-month intervals. If progressive heel-cord contractures are detected or if the pattern does not resolve spontaneously by age 3 years, treatment can be considered. Treatment is not necessarily required for a child with ITW who is without discomfort or functional limitations and who tolerates the cosmetic component of the toe-walking posture.

Treatment is usually offered to a patient with an underlying neurologic or muscle abnormality, on the grounds that such patients are thought to benefit in ambulation from plantigrade positioning of the foot with gait. 

If treatment is offered, nonoperative management (see Nonoperative Therapy) is the therapeutic mainstay and is always considered before operative management (see Surgical Therapy). If nonoperative modalities are not successful and surgery is chosen, options range from simple heel-cord tenotomy to multiple-muscle lengthening within the lower extremity. The optimal approach varies, depending on the underlying etiology of the toe walking.

Nonoperative treatment of toe walking includes stretching, casting, orthotics, and chemodenervation with botulinum toxin. The success of such treatment depends on the age of the patient, the severity of the equinus deformity, and the underlying etiology.

Stretching exercises are often the first treatment attempted for toe walking because stretching is the least invasive therapeutic measure. It is recognized that stretching and physical therapy offer a limited chance of success in treating ITW; accordingly, they are more often used in an attempt to maintain range of motion (ROM) gained by means of other methods. ^[8]

Stretching exercises must leverage the patient's body weight; the lower-extremity muscles are too powerful to allow effective passive stretching by parents or therapists. In one technique, the child is stood 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. Progressive stretch is accomplished by increasing the distance from the counter.

Williams et al studied the effect of applying whole-body vibration on heel strike, spatial and temporal gait parameters, and ankle ROM in children with ITW. ^[47]  Preintervention ankle ROM was compared with ROM immediately after and 20 minutes after intervention. Increases in heel contact and ankle ROM were observed immediately after intervention but were not sustained 20 minutes later. The gait improvement from whole-body vibration could be due to a rapid increase in ankle ROM or to a neuromodulation response. This potential treatment modality presents a nonrestrictive form of treatment, but its effects may not be lasting.

Serial casting is another nonoperative technique for stretching the Achilles tendon. ^[28] The child is placed in a below-the-knee plaster or fiberglass cast while the knee is flexed and the foot is dorsiflexed. This is most easily done with the child prone and with an assistant pushing gently downward on the forefoot. Once the cast has set, the gastrocnemius component stretches further as the knee extends. These casts are changed weekly or biweekly to progressively increase the range of dorsiflexion. Between cast changes, the child can walk with the use of cast shoes.

A custom orthotic, such as an articulated molded ankle-foot orthosis (AFO; see the image below), is another option for nonoperative treatment. This appliance is cosmetically acceptable, fits in a regular shoe, allows nearly normal ambulation, and prevents plantarflexion while allowing full dorsiflexion with every step. An AFO in a growing child can be expected to fit for 12-18 months before requiring replacement.

For toe walking due to muscle spasticity, stretching alone is ineffective. ^[32] Serial casting can be used to lengthen the Achilles tendon, but the contracture recurs rapidly unless the patient is maintained in an AFO. An articulated molded AFO, if used consistently, is an effective appliance for preventing the progression of spastic equinus that occurs with growth. If a patient with spasticity continues to toe-walk when AFOs 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 recur. ^[10]

Chemodenervation of the gastrocnemius-soleus complex muscles with botulinum toxin is yet another method of nonoperative treatment. Botulinum toxin causes temporary (~3 mo) selective muscle paralysis by blocking acetylcholine release at the neuromuscular junction. It was first introduced in the early 1990s as an injection into the gastrocnemius muscle in an attempt to decrease tone in patients with cerebral palsy (CP). ^[48] Its suggested indications subsequently expanded to ITW, but most studies have found it to have little efficacy in this application. ^[35]

A 2014 review of the literature by van Kuijk et al found preliminary evidence for beneficial effects of serial casting and surgery on passive ankle dorsiflexion, as well as on walking kinetics and kinematics, though normalization does not seem to occur. ^[49] In this article, botulinum toxin type A was not found to improve the results of casting. Only after surgery were sustainable effects lasting longer than 1 year reported. Effectiveness with respect to functional activities and social participation has yet to be demonstrated.

A single-center retrospective study by Filppetti et al (N = 28) assessed injection of incobotulinumtoxinA injection into the gastrocnemius medialis/lateralis muscles for the treatment of ITW in children. ^[50]  The injection yielded improvements in maximal passive ankle dorsiflexion, and this effect lasted as long as 6 months in some children. No adverse effects were reported. 

For toe walking associated with paralytic muscle disease, the use of regular stretching and orthoses together should be considered while the child remains ambulatory. Both modalities of nonoperative treatment are preferable to operative lengthening, which weakens the muscle and interferes with ambulation. Prolonged use of serial casts also weakens muscles and should be avoided. ^[11]

If conservative measures fail to correct ITW after about 12 months, operative lengthening can be considered if the ankle equinus is considered to be having a significant impact on the patient's gait. Complete Achilles lengthening is most commonly performed for ITW and is indicated if ankle equinus exists both with the knee flexed and with it extended. The procedure can be performed under a brief anesthetic by means of either open or percutaneous technique. ^{[9, 30]}

An open heel-cord lengthening is performed through either a longitudinal incision approximately 6-8 cm long placed medial to the Achilles tendon or a transverse incision at the level of the malleoli. A longitudinal incision centered over the tendon is avoided in order to decrease the risk of wound dehiscence and because the skin scar may contract and limit dorsiflexion.

The tendon sheath is opened, and the tendon is incised longitudinally over the full length of the exposure, so that it is divided into two equal halves. One half is detached proximally and the other half distally in a Z fashion. The two halves of the tendon are then sutured back together at the desired length. After the procedure, the patient is immobilized in a below-the-knee cast for approximately 6 weeks.

Percutaneous rather than open lengthening of the Achilles tendon is also an option for most patients with ITW. In this technique, an assistant holds 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, the medial half of the proximal tendon is divided. A second medial stab wound just above the distal insertion is made, and the anterior half of the tendon is divided. If the tendon has rotated a full 90º over this length, half of the fibers have been cut proximally and the other half have been cut distally. The assistant feels the tendon give, and the equinus contracture may then be corrected.

The amount of correction is controlled by immobilizing the foot and ankle in a below-the-knee cast in the desired position. If the tendon fails to part with two incisions, a third stab wound is made from a straight posterior approach, halfway between the first two incisions. Through this, the lateral half of the fibers is cut until the tendon gives.

Open or percutaneous complete Achilles lengthening can also be used to address toe walking in non-ITW, but lengthening must be judicious and may compromise gait function if global gait mechanics are not considered. For example, 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, heel-cord lengthening results in a progressive crouch gait with worsened overall function and should therefore be avoided. Such a patient may benefit from lengthening of the hamstrings and possibly the hip flexors, not the gastrocnemius. However, management of complex spastic gait is beyond the scope of this article.

Selective Achilles or gastrocnemius-soleus complex lengthening is often preferred in patients with muscle spasticity so as to avoid excessive weakening of ankle function. The segment of the gastrocnemius-soleus complex that is affected may be distinguished by means of the Silfverskiöld test (see Anatomy).

For example, a patients with hemiplegic spasticity involving one lower extremity would undergo selective gastrocnemius lengthening if the ankle can be brought passively to neutral with the knee flexed but falls into equinus as the knee is extended.  The gastrocnemius aponeurosis can be lengthened just before it joins the aponeurosis of the soleus (Vulpius or Baker) or at the gastrocnemius-to-Achilles muscle-tendon junction (Strayer procedure). ^[8]

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 has normal or near-normal strength. If the patient is using toe walking to generate an extension moment at the knee as compensation for a weak quadriceps, heel-cord lengthening causes premature loss of ambulation. All patients with Duchenne muscular dystrophy (DMD) during their last few years of ambulation use toe walking to compensate for weak knee extensors. Management of toe walking in such patients should be limited to nonoperative modalities (eg, bracing).

After a heel cord is surgically lengthened, the patient is typically immobilized in a below-the-knee cast for approximately 4-6 weeks. The position of the ankle is thought to be critical if a percutaneous approach was used; the ankle is placed into more dorsiflexion if more lengthening is desired and less dorsiflexion if less lengthening is desired.

Adequate pain control in the acute postoperative setting is imperative both to promote the child’s comfort and to reduce muscle spasms, which may alter the desired surgical correction. The limb(s) should be elevated for 2-3 days until acute swelling resolves. Weightbearing on the limb is routinely permitted if a percutaneous or open sliding tendon lengthening was performed. For patients who underwent open Z-lengthening, some surgeons prefer to defer weightbearing until tendon healing is sufficient (~6 wk).

The chief concern after operative heel-cord lengthening for treatment of ITW is recurrence. Although recurrence of ITW after surgery is uncommon, the authors have used molded AFOs for as long as 1 year to manage recurrence before considering repeat operative lengthening. The diagnostic workup should be revisited for any patient with recurrent ITW after surgery as a means of looking for signs of neuromuscular disease or intraspinal pathology that might not have been evident initially.

Recurrence after operative heel-cord lengthening is common in neuromuscular diseases, owing to continued spasticity and extremity growth. The appropriate use of an orthosis and stretching can help prevent this complication.

A feared postoperative complication for patients with toe walking secondary to spasticity or paralytic muscle disease is deterioration of independent ambulation. Such complications are minimized through careful preoperative evaluation and judicious selection, as well as meticulous execution of a heel-cord procedure. If function is adversely impacted by tendon lengthening, the foot and ankle should be supported with an orthosis.

Finally, wound dehiscence, necrosis, and cutaneous nerve injury may occur as complications, but they are relatively rare in this setting.

Once the cast has been removed, the patient may resume walking on the operated limb. A patient with ITW manifests a plantarflexion weakness out of the cast and runs flatfooted. The gastrocnemius-soleus complex typically regains strength slowly over the subsequent few months, returning to normal within 1 year. ^[51]  The patient is usually followed for 1-2 years after the surgical intervention to ensure that toe walking does not recur.

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 recurrence. In these patients, stretching, orthotics, or both are typically needed during growth to maintain foot position and prevent recurrence.