So once we have decided whether the contracture is dynamic or static, then our menu of treatment options is limited. If it is simply a dynamic problem that is causing the toe walking, we might observe that patient. If it is idiopathic toe walking, one would hope that they might eventually outgrow their tip-toe gait. If we want to try to control their overactive gastrocnemius, we might try to just hold it still with an ankle-foot orthosis, or AFO, like shown here. Or we might try to weaken the overactive gastrocnemius muscle with Botox injection, or with serial casting with disuse atrophy. However, if the child is tippy-toeing because the calf muscles are actually tight, causing a true Achilles contracture, then often surgical treatment is required. The more common treatments are, as shown here, a gastrocnemius recession procedure. This is done in the lower third of the leg posteriorly, cutting the gastrocnemius tendon in sort of a shape of a top hat, like this, and stretching the underlying soleus muscle. It is a very simple operation. If we need to get more than about 15 degrees of additional dorsiflexion to achieve our goal of 5 degrees dorsiflexion of the ankle, then we might need to do an Achilles lengthening.

Let us go back through now and review the early and late onset tip-toe gait, and a little bit more in detail with the differential diagnosis. It can be very difficult to distinguish between idiopathic toe walking and mild spastic diplegic cerebral palsy. It seems simple enough, but it really is not because both conditions are highly associated with premature birth, developmental delay and tight Achilles tendons. Now you can try to start sorting things out. If the patient can walk completely normal when you ask them to, it is more likely that they might have idiopathic toe walking. Of course the best way to distinguish between these two is to have definitive upper motor neuron signs, such as clonus, stretch reflex or Babinski.

You might be thinking, well, it is pretty easy to tell a child with CP, because they walk like this child on your right. The child with idiopathic toe walking basically walks perfectly normal has normal arm swing, perfectly normal balance and the knees are not hyperflexed. Yet, for some reason the child walks way up on tip-toes with their heels about as high off the ground as they can get them, even though their Achilles tendon is not physically all that tight. The child with moderately severe CP will walk like the child on your right, with abnormal arm swing, balance is not so good, and they will have some crouching many times from their tight hamstrings. They hold their hips and knees flexed and if you flex your knees enough, that almost forces you to raise your heels up off the ground. I might just caution you that the child who has very mild spastic diplegia can walk exactly the same as the child on the left with idiopathic toe walking. What else can we do to try to figure it out?

Apart from asking the neurologist to do things for us, we can order a dynamic EMG. Much of the early literature, and there has been a lot of it, about EMGs trying to distinguish between idiopathic and diplegic toe walking, show that there was a lot of overlap between these two groups, and the test was not very helpful to distinguish. A couple more recent articles that looked at very specific tests found that it can be a helpful if you do a dynamic EMG looking specifically for co-contractures when you are asking the child to extend the knee and then dorsiflex the ankle actively. If both the agonist and antagonist muscles are firing at the same time, this is pretty strong evidence that the patient has a spastic condition, and that seems simple enough.

To review, idiopathic toe walkers pretty much always have early onset toe walking. I want to mention that if a patient ambulates late, for instance a spastic diplegic patient ambulates at 2.5 years of age, that is late, but if they walk on tip-toes right from the outset of that 2.5 years, then we still call that early onset tip-toe. So idiopathic toe walkers have early onset tip-toeing and the literature shows a positive family history in 10-70% but the two largest studies, one by myself and one by a Dr. Eastwood in Great Britain, both showed 30-40% positive family history. These children will, by definition, have a normal neurologic examination, balance and behavior, and the Achilles contracture can be either dynamic or static. Now the real unanswered questions in this condition are, "Is it a problem for the child to walk for years on their tip-toes? Does it cause the tires to wear out? There is some concern that it might cause flat feet or calf pain or external tibial torsion. However the two larger studies really have not shown that there is any major damage that comes from this condition. Does it go away? Well, we assume so. We do not see a lot of adults walking around on tippy-toes unless they are wearing high heels. It was not until just recently that there was a podiatry article that did very long-term follow-up and concluded that for children who do not have tight Achilles tendons and have idiopathic toe walking, that eventually, after about 15 years or so follow-up, the condition resolves to the point where it is virtually undetectable clinically.

Finally, the big question is, "Is there any treatment that really helps this condition? In the past we have used casts and we have used surgical treatments, and casting probably is not very helpful. The three studies that talk about cast treatment for idiopathic toe walking have a follow-up of two months, and it does work that long, but the two larger studies that had follow-up of three years found that the children were still tippy-toeing, even though they were treated for a while with serial casting. Now what do I do for idiopathic toe walkers when they come to the clinic? If they just have an overactive Achilles, I try not to be too aggressive about that because I am a believer that it will eventually go away and that while it's going away, that it probably will not cause any significant damage. Surprisingly enough, I always ask this question "Is your child being teased about this? I always assume that kids being the way they are, that they really pick on that child who walks on their tippy-toes, and I have yet to hear a child say that this is a reason to be more aggressive about the treatment. If the family is not willing to just observe, then I will offer them casting but in the same breath I tell them that it is probably not going to be helpful in the long term. Most of them do not want to go through the expense and trouble. Then I tell them that Botox is an experimental treatment. There is no information about it. There is a study going on in Gainesville about it right now to see if Botox is helpful for idiopathic toe walkers. It makes sense that it might help and it certainly seems to help some in spastic diplegic patients.

For the idiopathic type toe walkers who have tight Achilles tendons, then I usually recommend a gastroc recession procedure to allow the heel to get to the ground but I have to warn parents that my own research shows a 30% recurrence rate in 15 children. Dr. Eastwood's study which was a slightly larger number of children had a 60% recurrence rate after surgery.

Spastic diplegic CP is again almost always early onset tip-toeing. The family history is negative and they should have upper motor neuron signs or dynamic EMG that is abnormal. We have to look close for crouching because that may contribute to the heels being up off the ground, and again they may have static or dynamic Achilles contractures. How would an orthopedist treat that type of toe walking? Again, if it is just an overactive Achilles, we would generally start with an ankle-foot orthosis, an AFO brace, and if the patient's dynamic contracture is so strong that they are fighting the brace, and then we might try casting or Botox to weaken the muscle and then continue with the brace. If the Achilles is physically tight, then a lengthening procedure would be used and perhaps a hamstring lengthening also if the patient is crouching significantly.

For psychiatric toe walking, there is just no literature about how to treat that. There is very little literature about it at all. It's seen once in a while in schizophrenic children, autistic children or children with learning disorders. The theory proposed by Weber is that children who have these various learning disorders get stuck in that very early stage where their tip-toe gait is temporarily normal and they never get past that. It seems to make some sense, I guess. Again psychiatric toe walking is early onset, family history may be positive, 15% of the time, the neurologic examination is usually grossly normal but behavior is not, and their Achilles contracture again may be static or dynamic. The treatment for psychiatric toe walking and there is zero literature about that also, and all I can tell you is that in my small experience, the outcome is even less predictable than idiopathic toe walkers which is already quite unpredictable, so I try to shy away from surgery when I can.

For the late onset toe walkers, we need to talk about Charcot-Marie-Tooth disease. Here the children walk normally usually until about 6 years of age or later, at which time they start to tip-toe. The family history may be positive. They should have lower motor neuron weakness, primarily in the peroneal nerve distribution, and the nerve conduction studies should be abnormal in the same nerve. Interestingly enough, these children tip-toe in part because their Achilles tendon is often slightly tight but usually the bigger part of the problem is that the front half of their foot points down. So they have forefoot equines, that is also called cavus deformity and that also tends to elevate the heel up off the ground even more.