YOUR CHILD’S FOOT: WHY DO CHILDREN TOE WALK?

Toddlers from age 1 to about 3 yrs of age may often exhibit toe walking. By age 2 to 3 the toe walking should disappear. Persistent toe walking after age 2, especially toe walking on one leg may be a cause for concern. A common problem associated with toe walking is Cerebral palsy, Autism, and Duchenne Muscular Dystrophy to name a few. These underlying disorders should be identified early on. A neurological examination needs to be done, including a test for language and developmental delays. If there are no developmental delays or muscle spasticity, then your child has what is known as “idiopathic toe walking”.

The most common problem neuromuscular disorder amongst toe walkers is Cerebral palsy (CP), affecting 1-7 in 1000 children. Not all children afflicted with CP are toe walkers. Less than 50% of children with CP walk on their toes. Another cause is Duchenne Muscular Dystrophy, a paralytic muscular disease, where children typically will walk on their toes.Spastic CP results in muscle spasticity, and is a common cause of toe walking.

Muscle spasticity can result from Spastic CP as well as from Spinal Cord lesions. Spinal cord lesions can be congenital, traumatic or acquired. It is important for you to see your Podiatrist as well as your Pediatrician regarding these disorders.

If your child is otherwise healthy, without any neuromuscular disorders, then your child may have what is called “Idiopathic toe walking”. This simply means that there is no defined cause for the toe walking. Toe walkers under this category may just have a habit of walking on their toes. Others may have a congenitally short Achilles tendon. However toe walking may also be associated with a short Achilles tendon. Casting or physical therapy and even surgery may be necessary to stretch and lengthen the calf muscles of the shortened Achilles tendon.

PHYSICAL EXAMINATION

A thorough physical examination must be done to evaluate where the deformity is originating from. The physical examination will determine where the spasticity or contracture of the Achilles tendon is coming from. Your Podiatrist or Pediatrician should be able to determine spasticity of the hamstrings or hip flexors. This exam may also involve a gait analysis or observation of your child walking at a regular pace.

TREATMENT

Toe walking which is not neuromuscular in origin (called idiopathic toe walking), has several first line treatment measures which can be incorporated. Some of treatments for a short Achilles tendon include stretching exercises, casting and orthotics. Remember, a toddler, under the age of 3 should just be observed.

On modality that is non-surgical and has good results is the molded ankle-foot orthosis (MAFO). This device fits in a regular shoe or sneaker, and a calf sock will conceal the device effectively. The MAFO allows only specific motions while walking and prevents your child from toe walking, since it does not allow the heel to come off the ground. With every step your child takes, the Achilles tendon is stretched. Most children have to wear this device for 6 to 8 months.

Even while wearing this device, (the MAFO) in the shoes, regular stretching should be incorporated during the day. Your podiatrist or pediatrician can teach you these exercises to stretch the Achilles tendon regularly.

With more severe cases, serial casting may be necessary to stretch the Achilles tendon. These casts are changed weekly and the Achilles tendon is manipulated and stretched more with each cast.

Toe walking which is more severe or is due to an underlying neuromuscular disorder will not be corrected with the above modalities. Surgical intervention may be the next line of treatment.

The most common surgical correction of the short Achilles tendon is lengthening of the tendon.

Your podiatrist or pediatrician will determine whether the toe walking is isolated to the heel or if the knees and/or the hips are contributing to the toe walking. All this needs to be determined prior to performing any surgery.

It is important to see your Podiatrist or Pediatrician if your child is walking on their toes beyond the age of 3.

How often do you look at your child’s feet?

Now that the weather is starting to warm up, you will have your children in slippers and sandals more often. This may be the best time to notice the way your child walks, and to observe their feet.

Even before your child starts to walk, you should observe their feet. Do they look “normal” to you? If you notice your baby’s feet turning in more than usual, or turning out excessively, you should consult your pediatrician and podiatric physician immediately. Some severe foot deformities, if caught early can be treated, preventing further complications when the child’s foot matures.

From birth to age 1, the foot grows tremendously. During this time, any abnormal pressure placed on the foot can lead to a deformity. The bones of the foot are very soft and moldable.

While your child in still in the crib, make sure to allow them to move around freely, especially allow the feet to move freely. Try not to keep your child in one position for too long. In order to allow the foot to grow normally, you must try to limit your child’s shoe wear, unless you are going outside of home. At home, keep your child’s foot in socks, or even barefoot. Excessive shoe wear can restrict growth and can place abnormal pressures on the foot bones, preventing them from growing normally.

When your child begins to walk, watch for their feet turning in while they walk or turning out excessively. Your podiatrist will be able to tell you where the deformity may be coming from. If caught early enough, bracing, orthotics, and casting can be used to correct the deformity. More severe deformities need surgical intervention.

Some common foot problems that you can encounter and that you should look for are:
1. Ingrown toenails which need to be treated immediately, before they result in an infection.
2. Warts, which children pick up on the soles of their feet. Warts are caused by a virus. There are various treatment options which your podiatrist can go over with you.
3. Metatarsus adductus, which is when the foot bends abnormally from the arch of the foot towards to toes. This can normally be corrected with just casting or orthotics, depending on the age of the child and the severity of the deformity.
4. Toe walking can be caused by several conditions. A mild condition can be corrected with stretching, and physical therapy. If the toe walking is persistent and cannot be treated with therapy or exercises, other causes of the toe walking have to be evaluated. These include neuromuscular deformities, including Cerebral Palsy, Muscular Dystrophy, Limb length discrepancies, and a short Achilles tendon.
5. In-toeing is when the toes point inwards while your child walks instead of pointing straight ahead. In-toeing can cause the child to trip and fall excessively. If this lasts until the child is 1 ½ to 2 years old, you should seek medical attention. You podiatrist can evaluate the severity of the problem, and can suggest various treatment options, including orthotics or casting.
6. Out-toeing is not as common as in-toeing. Out-toeing is when the toes point outwards while your child walks. At about the age of 2 you may notice a sight out-toeing of your child as part of the normal development. If this out-toeing is excessive, it can also be treated if caught early.

There are many other deformities of the foot which can be found in children. These are less common and are more severe than the deformities listed above. These include deformities such as clubfoot and vertical talus.

If you notice any abnormality of the foot or ankle in your child, or if your child has pain, and trips and falls a great deal while walking, then it may be a good idea to see your pediatrician as well as your podiatrist for evaluation.

Early diagnosis and treatment of a foot deformity in children is essential for normal growth of a child foot.

By: Sharon Joag, DPM