SLR - June 2018 - David C. Hatch Jr.
Idiopathic Toe Walking: Prevalence and Natural History from Birth to 10 Years of Age
Reference: Engström, Pähr, MD, PhD; Tedroff, Kristina, MD, PhD. Idiopathic Toe Walking: Prevalence and Natural History from Birth to 10 Years of Age. J Bone Joint Surg Am. 2018 Apr 18;100(8):640–647
Scientific Literature Review
Reviewed By: David C. Hatch Jr., DPM
Residency Program: Tucson Medical Center/ Midwestern University Podiatry Residency Program, Tucson, AZ
Podiatric Relevance: Encounters with children demonstrating persistent toe walking can often be frustrating for clinicians as well as parents. With a relative dearth of research directed toward this concerning gait type, clinicians may find difficulty in comforting, explaining or discussing prognoses with caregivers of this population. Additionally, clinical indications for casting, tendo-achilles lengthening (TAL) and bracing may be poorly defined in patients without demonstrable deformity on examination yet persistent toe gait in ambulation. This article documents a longitudinal evaluation, “natural history” of children with this gait type. It adds information and insight to discussions of toe gait treatment and prognosis with concerned parents.
Methods: A group of 1,436 children were evaluated for presence and/or history of toe walking at a regional health clinic at standardized checkups at the age of five years, six months. After the determination of the presence of toe walking between the ages of five and six, the researchers continued to follow the patients to ages eight and 10. Follow-up evaluations, questionnaire and physical were intended to specifically identify persistence in toe walking and instances of spontaneous resolution. Questionnaires asked caregivers to estimate the percentage of time the patient demonstrated toe walking. Physical examination included evaluating ranges in motion of the hips, knee and ankle joints, as well as neuromuscular and reflex tone.
Results: Of the 1,436 children, 1,401 were without known neuromuscular or neurodevelopmental disorder, of which 63 (4.5 percent) were or had been toe walkers at the age of 5.5. Twenty-six (1.9 percent) persisted in toe walking at the age of 5.5 with spontaneous resolution of almost 60 percent of toe walking gait in children age 5.5. At the eight-year follow-up, six (23 percent) of those demonstrating persistent toe walking gait demonstrated spontaneous resolution, and four children (15 percent) underwent percutaneous TAL. At the 10-year mark, an additional seven children (27 percent) demonstrated spontaneous resolution, while one child (1.6 percent) underwent operation for flexion contracture. In summary, at the age of 10, only eight of the 63 children (13 percent) demonstrated persistent toe walking gait, 50 of the children (79 percent) demonstrated spontaneous resolution and five (8 percent) of the population underwent operative intervention for correction.
Conclusions: This longitudinal “natural history” evaluation of toe walking gait supports prior hypotheses that toe walking gait may be a largely (79 percent) transient condition and likely to spontaneously correct by the age of 10. Conversely, the findings in this article question prior treatment recommending surgical intervention in patients demonstrating toe walking without clinically identifiable ankle contractures. In patients demonstrating ankle contractures as a contributing pathology to toe walking, surgical intervention remains recommended. In populations of idiopathic toe walking past age 5.5, patient routine observation for neuromuscular, neurodevelopmental or attention disorders may be indicated. Proper patient evaluation, combined with the natural history provided by this research and understanding of three likely etiologic categories (idiopathic/transient, neuromuscular or neurodevelopmental and ankle contracture), may now help establish a more thorough and informed conversation as to the cause, treatment and prognosis of this concerning and difficult condition.