1. What happens if we do not treat ITW

    J Am Podiatr Med Assoc. 1997 Jan;87(1):17-22.
    Effect of persistent toe walking on ankle equinus. Analysis of 60 idiopathic toe walkers.

Sobel E, Caselli MA, Velez Z.

New York College of Podiatric Medicine, New York, USA.

Sixty idiopathic toe walkers (age range 1 to 15 years) were evaluated to determine the natural history of toe-to-toe gait and the relationship between the range of ankle dorsiflexion and increasing age. The majority of toe walkers had a normal birth weight (average 7.06 pounds), walked on time (average 11.14 months), began toe walking immediately (87%), stood plantigrade (90%), were able to demonstrate a heel-toe gait (88%), and toe walked intermittently (68%). Forty-six percent of all toe walkers were found to have 0 degree or less of passive ankle dorsiflexion. Equinus toe walkers (mean dorsiflexion -5.2 degrees) had significantly less dorsiflexion than the remaining toe walkers (mean dorsiflexion 16.9 degrees; p < 0.01). An average of 12 degrees of dorsiflexion was resent in the 1-to 2-year age group, which gradually diminished to -4 degrees in the 6- to 15-year age group. It appears that there may be a relationship between persistent toe walking and the development of ankle equinus in some children and therefore interventions should be considered to inhibit the toe walking progression.

The article concludes that toe walkers where there is equinus deformity need treatment to improve dorsiflexion

2. What are the results of conservative treatment and serial casting?

Acta Paediatr. 2004 Feb;93(2):196-9.
The natural history of idiopathic toe-walking: a long-term follow-up of fourteen conservatively treated children.
Hirsch G, Wagner B.

Department of Paediatric Orthopaedics, Astrid Lindgren’s Children’s Hospital, Karolinska sjukhuset, Stockholm, Sweden. georg.hirsch@ks.se

AIM: To determine the long-term results after conservative treatment (physiotherapy, casting, orthoses, or a combination of these) of idiopathic toe-walking (ITW). METHODS: Tiptoe-walking is diagnosed as idiopathic (habitual) if no signs of neurological, orthopaedic, or psychiatric disease are detected. The diagnosis is one of exclusion. Sixteen former patients with ITW, all now at least 13 y old, were asked to participate in a follow-up investigation 7-21 y after being first diagnosed. Two cases were excluded because heel-cord lengthening had been performed later on in other hospitals. The remaining 14 patients completed a questionnaire. Eleven patients consented to a clinical examination, during which they were videotaped and their active and passive ankle-joint dorsiflexion measured. These data were compared with the assessment at the initial evaluation. In one instance, the toe-walking ceased after conservative treatment (plaster cast). In all other cases the toe-walking pattern recurred. RESULTS: At follow-up three patients showed some toe-walking when they were unobtrusively observed. When videotaped, they did not toe-walk, although a distinct heel-strike was missing. The remaining eight patients all walked with a heel-strike. Two patients had slight symptoms possibly related to toe-walking. No fixed contracture was present at the first evaluation, and none was found at follow-up. There was no systematic change in ankle-joint dorsiflexion from initial assessment to follow-up examination. CONCLUSION: Non-surgical treatment of ITW does not have a lasting effect and the long-term results in this study are considered to reflect the natural history, i.e. the toe-walking pattern eventually resolves spontaneously in the majority of children. Surgical treatment of ITW should be reserved for the few cases with a fixed ankle-joint contracture.

The article concludes that toe walkers where there is equinus deformity need treatment to improve dorsiflexion

Acta Orthop Belg.  2006 Dec;72(6):722-30.
Serial casting in the treatment of idiopathic toe-walkers and review of the literature.

Fox A, Deakin S, Pettigrew G, Paton R.

Blackburn Royal Infirmary, Blackburn, United Kingdom. annafox2k@btopenworld.com

Idiopathic toe-walking is defined as persistent toe-walking in a normal child in the absence of developmental, neurological or neuromuscular conditions. True idiopathic toe-walking is a rare referral, representing approximately 1:100 new patients seen in the Paediatric Orthopaedic Clinic. A prospective study of idiopathic toe-walking (ITW) was organised between 1999 and 2003. Patients underwent full history, neurological examination and assessment of ankle dorsiflexion, followed by below-knee weight-bearing casting. Forty four developmentally normal children with no delay in walking age were in this study. There was an age range on presentation from 2 years to 14 years 4 months, with median 60.5 months. Sixty eight percent were male. Thirty four percent had a family history of the condition. Following casting, 66% of patients had improved gait on patient and clinician determined outcomes, with the majority of children ceasing to toe-walk. Ankle dorsiflexion significantly improved in those children who were successfully treated (p = 0.001).

The article conclused that in one third of patients the serial casting did not work these are likely to be patients with ankle equinus

3. What is the outcome of surgery for ITW

J Pediatr Orthop.  2006 May-Jun;26(3):336-40.
Outcome of patients after Achilles tendon lengthening for treatment of idiopathic toe walking.

Hemo Y, Macdessi SJ, Pierce RA, Aiona MD, Sussman MD.

Dana Children’s Hospital, Tel Aviv Medical Center, Tel Aviv, Israel.

Fifteen children who were diagnosed with idiopathic toe walking that cannot be corrected by nonoperative treatment were assessed by clinical examination and computer-based gait analysis preoperatively and approximately 1 year after Achilles tendon lengthening. Passive dorsiflexion improved from a mean plantarflexion contracture of 8 degrees to dorsiflexion of 12 degrees after surgery. Ankle kinematics normalized, with mean ankle dorsiflexion in stance improving from -8 to 12 degrees and maximum swing phase dorsiflexion improving from -20 to 2 degrees. Peak ankle power generation increased from 2.05 to 2.37 W/kg but did not reach values of population norms. No patient demonstrated clinically relevant triceps surae weakness or a calcaneal gait pattern. Seven patients had a stance phase knee hyperextension preoperatively, and 6 of these corrected after surgery. Achilles tendon lengthening improves ankle kinematics without compromising triceps surae strength; however, plantarflexion power does not reach normal levels at 1 year after surgery.

The article conclused that surgery in selected cases who do not improve with conservative treatment improves ankle dorsiflexion and way the child walks inclusing the energy efficiency. There may be calf weakness post operatively which corrects in one year time

J Pediatr Orthop.  2001 Nov-Dec;21(6):790-1.
Simplified approach to idiopathic toe-walking.

Kogan M, Smith J.

Primary Children’s Medical Center, Salt Lake City, Utah, USA.

Controversy exists as to the treatment of idiopathic toe-walking (ITW). Since 1993, the authors have managed children with ITW using an outpatient percutaneous lengthening of the Achilles tendon, followed by placement of below-knee walking casts for 4 weeks. The authors reviewed 15 children who were treated for ITW with percutaneous Achilles tendon lengthening between 1993 and 1999. Ten of the 15 patients could be contacted for a follow-up survey. None of the parents stated that their child’s toe-walking had recurred. There were no painful scars. All of the children were able to keep up with other children and did not notice any calf weakness. Two children had occasional Achilles tendinitis, which was relieved with antiinflammatory medications. All parents were satisfied with their child’s outcome. The authors believe that percutaneous tendo-Achilles lengthening in ITW greatly simplifies the management of ITW.