Epidemiology
70% male
70% positive FHx
20% learning difficulties
DDx toe walking
Early / late onset
Unilateral / bilateral
1. Habitual
Toddlers - child can heel walk
2. Structural
Fixed equinus - CTEV / arthrogryposis
Short / tight T Achilles
Space occupying lesion in calf
3. Neuromuscular
CP
Spinal dysraphism
Duchenne's Muscular Dystrophy
CMT
4. Short Leg
Real (DDH)
Apparent (knee or hip deformity)
Natural History Habitual
Initially toddlers walk on toes 3-6/12
- graduate to strike on flat of foot
- rinally develop normal heel-toe gait
- mature gait pattern by 3 years
Idiopathic Toe walker
- normally bilateral
- usually from birth
Beware 5 year old who has recently begun to toe walk, especially unilateral
History
Gestational
Birth
Family history
How long on tip toes ?
Walking age
All the time or not ?
Examination
Rule Out
1. CP
2. Duchenne's MD
3. CMT
4. Short Leg / DDH
5. Dysraphism
Hip
- Trendelenberg
- LLD
Spine
- signs spinal dysraphism
- scoliosis
Gait
- Heel / Toe walk
- running coordination - hemiplegic / brings out very minor posturing / look at UL
Gower's sign
- Duchenne's muscular dystrophy
- ask to squat then stand up
- have to hand walk up their legs as severe proximal muscle weakness
Upper limbs
- for hemiplegia, increased tone
Foot
- active +/- passive ROM
- sole of foot - if always on toes then heel will be soft
- Silverskiold
Neurological exam
- especially abdominal reflexes
Investigations
Spine Xray / MRI
Gait analysis
EMG
Serum CPK
- DMD > 5000
- proceed to muscle biopsy if elevated
Nerve biopsy - rare but may need in peripheral neuropathy
Management
Non Operative
Stretches
Serial casting
Botulinum A toxin in CP
AFO
Operative
Percutaneous T achilles lengthening
Timing
- ? about 7 years or older
- wait till at least > 4 years
- many resolve by age 10
Results
- 75% will still toe walk after treatment