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Melanie: There's no handbook for your child's health, but we do have a podcast, featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. Welcome to Kids Health Cast by Weill Cornell Medicine. I'm Melanie Cole, and I invite you to listen as we discuss toe walking. My guest is Dr. Dara Jones. She's an attending physician of pediatric physiatry and an Assistant Professor of Clinical Rehabilitation Medicine and Clinical Pediatrics at Weill Cornell Medicine. Dr. Jones, it's a pleasure to have you join us today. Tell us what is toe walking and what's the prevalence of this?

Dr Dara Jones: Hi, Melanie. Thank you so much for inviting me. Toe walking is walking on the toes or on the forefoot, pretty much as it sounds, without a heel strike on initial contact of the foot during the stance phase of gait. It's fairly common and can occur as a typical part of childhood development up until around the age of two years old.

Melanie: Do we know what causes it?

Dr Dara Jones: There are a lot of causes potentially for toe walking. Again, up until the age of two, it's considered normal. But if it persists beyond this age, it can be caused by a number of different things. It can be related to child behavior, trauma or fracture, length of the calf muscle or Achilles tendon. It can be due to a difference in leg length. It can be caused by muscle weakness or other neurologic conditions.

Melanie: Is there any truth-- I mean, some parents might be concerned that it's a symptom of autism. Is that true?

Dr Dara Jones: Well, it can be. So approximately 40% of children who have neurodevelopmental or neurobehavioral conditions can be toe walkers, but it can also be a symptom of numerous other conditions, which is why it's important for it to be evaluated.

Melanie: So then tell us what's the next step? You mentioned the age. What's involved in diagnosis and what's the next step for parents? Who do they even go to if they start to notice this?

Dr Dara Jones: Right. So the most important next step is to see someone who specializes in children neurologic and musculoskeletal conditions. So that can be either a pediatric physiatrist like myself, a pediatric orthopedic surgeon, or a pediatric neurologist. And it starts with a very thorough medical history and physical examination.

There can be aspects of the birth history or the developmental history or the child's general function. especially as it pertains to the pattern and frequency of their toe walking that can help further narrow down the potential reasons for toe walking. And then following that, a detailed physical exam, watching the child while they walk, especially prior to them realizing that they're being observed and assessing their motor skills and whether or not they're appropriate for their age can also further help identify potential causes.

Melanie: So once you've done that, are there treatment options? Is it a watch and wait? Can it be corrected? Tell us what you would do in this case.

Dr Dara Jones: So the guidance for treatment generally begins with understanding the cause. And then following that, identifying whether or not the child has an ankle contracture. So for the case of idiopathic toe walking, for example, which is the most common reason for toe walking, if there's no contracture, one option may be to prescribe special orthotics called ankle foot orthotics, which help promote a heel strike.

However, these improvements we've found are not necessarily sustained once the braces are stopped at six weeks. If there is a contracture present, sometimes casting the feet in a position of maximal what we call dorsiflexion, being able to flex the foot upward, over a period of several weeks can help improve the range of motion.

Only if the contracture is severe enough, would a consultation with an orthopedic surgeon be recommended for potential surgical lengthening.

Melanie: Well, Dr. Jones, then what are the outlooks for children that toe walk early in life? And how have been your outcomes? Tell us what you've seen with these kids.

Dr Dara Jones: So we've learned from a large study that looked at the natural history of toe walking between birth and 10 years of age, that about 4.5% of healthy children toe walk at some point between the time they were born and by the time they were five and a half years old. And at five and a half, only about 2% of those children were still active toe walking.

And then if you look at those active toe walkers, by the time they turn 10, nearly 80% of them stopped toe walking on their own without any medical intervention. So, really, unless the child has some significant restriction in their range of motion, which is fairly rare, is more intensive treatment generally recommended.

So the overall, the long-term outlook is very favorable. But it does bear repeating that an evaluation by a specialist is really critical to help guide the diagnosis and guide the treatment. And that will in turn dictate what the prognosis is.

Additionally, other treatment options aside from watching and waiting can be a referral to physical therapy for home stretching exercises and gait retraining. However, we have found over the years that there's not really a significant amount of evidence that shows that physical therapy and home stretching exercises actually provide improvement.

However, it's still a common recommendation and one that I do employ in my practice as it can sometimes be helpful. It's not uncommon for there to be an underlying sensory processing impairment that may lead to toe walking. And in those cases, children do respond better to earlier treatment. And not only that, but physical therapists are also able to take the time to perform more standardized assessments of the child's gross motor function that can pick up on subtle changes in a child's development and help give the physician more information regarding a diagnosis.

Melanie: Do you have any final thoughts for parents and especially parents of toddlers, kids that are just starting to walk, and it's a really exciting time, Dr. Jones, but they notice toe walking, which as you said, can be a normal part of this whole adjustment and learning to walk? It can be something more serious. What would you like to tell them about that and when you feel it's important that they tell their pediatrician or refer to a specialist?

Dr Dara Jones: The most important thing really to emphasize is that there's no significant cause for concern, unless the child is over two years of age or if there are other developmental delays that are associated with it. But if it's generally typically developing child who is otherwise doing everything that they should be doing, there's no significant reason for concern. It's really only once the child becomes older, that it should warrant more investigation.

Melanie: Thank you so much, Dr. Jones, for joining us today and sharing your expertise on toe walking.

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That concludes today's episode of Kids Health Cast. We'd like to thank our listeners and invite our audience to download, subscribe, rate, and review Kids Health Cast on Apple podcasts, Spotify and Google podcast. For more health tips, please visit WeillCornell.org and search podcasts. And don't forget to check out our Back to Health. I'm Melanie Cole.

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