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.
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 both tip toes.
Walking on Tip Toes 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 tip 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
(calf muscle). The patient who has a severe achilles
tendonitis (pain in the back of the calf muscle) or
severs calcaneal apophysitis (heel pain) might tip toe
to take some of the tension off of their achilles tendon.
A rarer cause of a child tip toeing on one side only
could be deep muscular calf hemangioma, this is a vascular
neoplasm which causes swelling of the calf muscle.
Walking on Both Tip Toes
The most cause common is idiopathic
toe walking (no known cause), also called habitual toe
walking.Walking on tiptoes is quite
common between 10 and 18 months when children are learning
to walk. In some children it simply becomes a habit,
when asked to walk normally they put their heel down
on the ground before their toes. It's just that when
they're not concentrating they seem to revert to walking
on their toes.
Mild spastic diplegic cerebral palsy is
also very common. Then more rarer conditions that can
cause children on walking on both tip toes are 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.
Early onset tip toeing is defined as
tip toeing that occurs within three months of the the
child walking. Far and away the two most common reasons
for this are idiopathic toe walking and spastic diplegic
cerebral palsy. Cerebral palsy refers to a group of
conditions that affect control of movement and posture.
Because of damage to one or more parts of the brain
that control movement, an affected child cannot move
his or her muscles normally. While symptoms range from
mild to severe, the condition does not get worse as
the child gets older. With treatment, most children
can significantly improve their abilities.
Late onset tip-toe gait is defined as
tip toeing which begins at least about four months after
a patient has had a well-developed normal heel-toe walk.
This is virtually always due to some neuromuscular problem
which will require an examination by a neurologist.
It is also important to note if their
was a family incidence of tip toe walking. One of the
most common contributing factors is a tight achilles
tendon. Normally, a child should have about 10 degrees
of ankle dorsiflexion (the amount your foot can extend
towards your body when the foot is not tensed); however,
a child can walk with a normal heel-toe gait as long
as they can get to this neutral (The sub taler joint
in the ankle is neutral when it is neither twisted in
nor twisted out.).
Treatment
Most children will need to be referred
to a physiotherapist, orthopedist and neurologist for
treatment.
Idiopathic toe walking may be cured by
just observing the condition and hoping that the child
might eventually outgrow their tip toe gait. If you
want to control an overactive calf muscle then the doctors
might try to just hold it still with an ankle-foot orthosis
(AFO Brace). If it is being caused by a tight achilles
tendon then surgery may be required. The most common
procedure is a gastrocnemius recession procedure. An
alternative could be casting to correct the achilles
tendon.
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. However a good sign is if the child
can walk completely normal when you ask them to, it
is more likely that they might have idiopathic toe walking.
For psychiatric toe walking, there is
just no literature about how to treat this. 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. There are no relevant
treatment option that have been documented for this.
Spastic diplegic cerebral palsy is again
almost always early onset tip toeing. The family history
is negative and they should have upper motor neuron
lesions or dynamic EMG (Electromyography is a test that
assesses the health of the muscles and the nerves controlling
the muscles) that is abnormal. If their is an over active
achilles tendon then you could use bracing. If a patient's
dynamic contracture is so strong that they are fighting
the brace, and then the doctors might try casting or
Botox (Botox is an experimental treatment) 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.
Signs of upper motor neuron lesions include
weakness, hyperreflexia (Reaction of the autonomic (involuntary)
nervous system to over-stimulation), and increased tone.
Note that with acute upper motor neuron lesions there
is often flaccid paralysis (weakness or loss of muscle
tone resulting from injury or disease of the nerves
innervating the muscles) with decreased tone and decreased
reflexes.
Most children will eventually
outgrow their tip toe gait but if you have any doubts
then you should visit your family doctor as the first
point of call.
You
are here: 
