I chose this topic and I hope you find it interesting. It is not as cool as cancer and DNA and infections, but it is something that you will see. I know I see tip-toeing children in about 2% of my practice so you are going to see it in your clinics as well.

This is what we will be talking about. This is the toddler, the 3 Year-old who walks into your clinic waiting room walking on tip-toes. Here in the Miami we cannot blame that on a cold floor. Mom gives a history that the child walked at the normal time, but has always walked on tippy-toes. It was cute in the beginning but now the child is getting ready to go to preschool and mom is a little concerned that he might get teased. What should be done about that? The first thing we need to do is figure out if it is normal. Can it be normal to walk on tippy-toes? Surprisingly enough, there were a couple of researchers and one of them, Dr. Sutherland in L.A. found that there is a brief period of time where children may tip-toe intermittently, and it would be considered normal for that brief period of time right when children first start to walk up until maybe just after 2 years of age. After that, it is no longer considered normal to walk on tip-toes bilaterally.

As you can see here, a normal gait is called a heel-toe gait and that means that as one leg swings forward, it lands with the heel on the ground first. Then the body proceeds over that stance phase limb and finally the foot raises up on tip-toe right before it swings forward again. As you can see, when the leg is on tip-toe, the other leg is on heel strike so in normal gait there is never a time when a child should be on tippy-toes bilaterally.

I could talk about unilateral tip-toe gait but I only have 30 minutes so I will just mention that there are some common reasons for a child to walk on tip-toe just on one side. One of the more common reasons is that one leg is quite short and if the leg is more than about 3 cm short, a child will often compensate by tippy-toeing so that the leg reaches the ground. A child that is spastic in one leg or one side of the body may tend to tip-toe on that side because of the overactive gastrocnemeus. The patient who has a really rip-roaring Achilles tendonitis or Severs calcanea epiphysitis might tip-toe to take some of the tension off of their Achilles tendon. I have been in the business long enough that I have actually seen the bottom three and they are all considered quite rare causes of unilateral tip-toeing. Deep muscular calf hemangioma can cause it. Morphia or linear scleroderma behind the ankle can cause a soft tissue contracture with an equinous deformity. I even had one patient. I have to tell you this story. It was a teenage girl who just moved to Miami from Colombia. Two years before, her leg had been lightly trampled at a rock concert and ever since that event she walked on tip-toes. I did not have a lot of information about the initial injury but basically when I examined her, her foot was in maximum equinous. I could not push it up at all and of course being a surgeon, I recommended surgery to fix that. I took her to the operating room and as soon as the anesthesiologist put her to sleep, she had perfect ankle motion. She did not have a tight Achilles tendon at all and I was completely fooled by her psychological conversion reaction which is what we finally figured out was going on. I have not been fooled since, but it was one of those cool cases that you will never forget.

I am going to talk about bilateral tip-toe gait and this is a menu of things which should go through your mind when you see a child walking on tip-toe bilaterally. The more common ones are idiopathic toe walking, also called habitual toe walking. Mild spastic diplegic cerebral palsy is also very common. Then things get less common as you go down the list. There are things that should not be forgotten like Charcot-Marie-Tooth peripheral neuropathy or muscular dystrophy, such as Duchene. Then, even some less common things like autism, schizophrenia and finally spinal cord anomalies and juvenile type multiple sclerosis.

We have to start sorting out that differential diagnosis. How can we do that? I follow the 'Toe Walkers Anonymous 4-step Plan'. I basically try to answer four questions and if you do this, you will be well on your way to having the diagnosis, the prognosis and even knowing what the orthopedic surgeon is likely to recommend for treatment.

The four questions are: When did the tip-toe gait begin? Is there a family history of similar tip-toeing? Is the neurologic examination normal or abnormal? Is the Achilles tendon physically tight or simply overactive?

That first question is designed to help distinguish early onset from late onset tip-toeing. Early onset tip-toeing is defined as tip-toeing that occurs within three months of the initial onset of ambulation. Far and away the two most common reasons for this are idiopathic toe walking and spastic diplegic cerebral palsy. Much less common are some of these psychological and learning disorders such as autism, schizophrenia and mental retardation.

Late onset tip-toe gait is defined as tippy-toeing which begins at least about four months after a patient has had a well-developed normal heel-toe gait. This is virtually always due to some neuromuscular problem. So right away, if you see that, your mind should be thinking that this patient needs to be evaluated by a children's neurologist to help figure out the diagnosis, if it does not seem to be something fairly obvious. So again, things that may cause late onset tip-toe gait are things like Charcot-Marie-Tooth, Duchene, muscular dystrophy, some spinal cord anomalies and juvenile MS.

Question two is about family history. Orthopedists are not good at taking family histories but it is important in this condition because it is helpful if you get a positive response to the question. Idiopathic toe walkers, for some reason, seem to have a positive family history roughly 40% of the time. So if mom says, "Oh yes, there are three other siblings that all walked on tip-toes" or "yes, the child's father did the same thing when he was young", you would then be steered in that direction. Spastic diplegic cerebral palsy, unless there are complications of multiparity, does not usually have a positive family history. And of course if mom says, "Oh yes, the father has schizophrenia". Well again, that might steer you in the right direction by telling you that the child is tip-toeing because of psychiatric problems.

A family history can also be helpful for the late onset tip-toers. If mom says, "Oh yes. Charcot-Marie-Tooth runs in the family". You will have your answer right there. Duchene muscular dystrophy also has a positive family history about half the time because it's an X-linked condition. Spinal cord anomalies rarely have a positive family history.

Question 3 is also very helpful because again it starts to sort out some of the finer details in the differential diagnosis. By definition, idiopathic toe walking has to have normal neurologic and behavioral exam, at least if there is such a thing as normal behavior in children. There will be no upper or lower motor neuron signs in an idiopathic toe walker. Spastic cerebral palsy, by definition, has to have upper motor neuron signs, but this can be quite subtle sometimes. You may have to call in a neurologist or get a dynamic EMG to help answer this question. In the psychiatric exam, there should be no neuropathy; however, the behavior exam may be quite abnormal. Charcot-Marie-Tooth, by definition has to have peripheral neuropathy, and again it would mostly involve the peroneal nerve distribution and it may take nerve conduction study to prove this. Duchene will not have neuropathy but has primary myopathy and will look very much like a generalized lower motor neuron condition. Spinal cord anomalies may have upper, lower, or both motor neuron problems, depending on which portion of the cord is most affected.

The fourth question is, "What kind of Achilles contracture is present? This is not at all helpful for the differential diagnosis of tippy-toeing. It is basically a question that the orthopedist answered before deciding on treatment, and again he also needs to know the diagnosis. Answering the question, "Is the Achilles tendon truly tight?" really requires knowing how to measure it properly. It is not just simply a matter of pushing the foot up to maximum dorsiflexion. In order to really measure true ankle dorsiflexion, one has to have the child's knee in maximum extension, and the midfoot joint, the talonavicular joints have to be stabilized. Then the foot is pushed to maximum dorsiflexion, as shown in this example. Normally, a child should have about 10 degrees of ankle dorsiflexion; however, a child can walk with a normal heel-toe gait as long as they can get to this neutral or 90 degree ankle dorsiflexion. Why is it important to stabilize the midfoot joint? Because if you do not, children who often have significant ligament laxity or even flat feet, may subluxate through that talonavicular joint when you are dorsiflexing the foot. If it is not stabilized with your thumb, you may get an additional 5-10 degrees of false dorsiflexion through that talonavicular joint.