Introduction
The tip-toe gait is observed in about 5% of pre-school age children. Strictly speaking, the term tip-toe gait is not quite correct, since children walk on their forefoot, with their toes lying flat on the ground and the rolling motion largely absent. The term “toe gait” would therefore be more appropriate. Children with such a gait pattern are more often presented to an orthopedist. If a toe gait is present for more than three months, it is called “persistent” (lasting).
Causes
In many children, even intensive diagnostics and questioning do not reveal any cause of the tiptoe walk. Thus, there is no physical or psychological illness underlying the disease, tiptoeing occurs for unknown reasons. One speaks here of idiopathic (unknown cause) or habitual (habitual) tiptoe.
The habitual tiptoe can be divided into 3 forms. Type I accounts for about 1/3 of all cases, where the cause is a shortening of the muscles. Therefore, children cannot stand on the entire foot surface and their balance is affected.
In type II, the tiptoe gait is more common in the family, so it is based on a genetic component. This type 2 occurs in slightly more than half of all idiopathic tiptoes. The children can then stand on the entire surface of the foot and also walk in the normal heel walk when asked to do so, but for this to happen, the hip must be rotated outwards.
Type III is called “situational tiptoe gait”. The children can walk in the heel walk without any problems, only under stress (in certain situations) do they involuntarily return to the tiptoe walk. Type III patients are also sometimes conspicuous for concentration problems and unusual behavior.
During their childhood, many of these children develop a perfectly normal gait without medical treatment. Especially in children who are in the process of learning to walk, a tiptoe gait often occurs, which usually changes into a normal gait pattern after 3 to 6 months. It is important to note that the idiopathic tiptoe walk is always a diagnosis of exclusion, which means that other diseases must first be excluded in order to be able to make this diagnosis.
In idiopathic or habitual tiptoe gait, the Achilles tendon is often shortened. The calf muscles are also contracted (tense). There is disagreement among physicians as to whether these two symptoms are the consequence or cause of the toe walk.
There are numerous neuromuscular diseases in which a tiptoe walk can appear as a symptom. The causal disorder can be located on all levels from the brain to the performing muscle. The cerebrum, which gives the command for the muscle contraction, or the spinal cord, which relays the commands, are particularly noteworthy.
The associated clinical pictures are, for example, spastic cerebral palsy or delayed maturation of the tractus corticospinalis (a strand of the spinal cord). It is often difficult to distinguish them from idiopathic tiptoe disease. In idiopathic tiptoe gait, the foot is bent as if the child were standing on its toes, even with the knee bent.
In spastic cerebral palsy, on the other hand, when the knee is bent, the foot often returns to an extension position (tiptoes pointing to the nose). The delayed maturation of the tractus corticospinalis is more common in some families, where the tip-toe gait usually changes to a completely normal gait pattern at the age of 6 to 8 years. Progressive muscular dystrophy, a hereditary muscular disease, can also lead to tiptoeing due to the increasing susceptibility of the muscle fibers.
It is typical here that children first develop a normal gait pattern and only subsequently change to tiptoeing. Furthermore, various nervous disorders can lead to tiptoeing. The clubfoot is a congenital malposition of the foot, which often occurs on both sides.
Due to this malpositioning, tip-toeing can occur. Often the affected children learn to walk late and are conspicuous for their unsafe walking. Studies have shown that tiptoeing occurs far more frequently in mentally retarded children than in other children.
One assumption is that these children have a disturbed sense of balance and the tip-toe gait helps them to obtain more precise information about the balance position from the ankle joint.Another theory says that the children are retarded in their development and thus initially stopped at a level of learning to walk where heel gait is not yet mastered. Autism is a serious developmental disorder that affects the transmission and processing of information. Even in early childhood, those affected are conspicuous by their lack of communication and social interaction skills.
In addition to stereotypical behavioral patterns and strikingly good abilities in attention, intelligence and memory, difficulties in coordination are characteristic. For example, tiptoeing is observed in up to half of the autistic children, whereas adult autistic children usually do not walk on tiptoe. The affected children also sometimes move in a hopping, whirling or stilted gait.
Researchers suspect that the children thus compensate for a vestibular (affecting the sense of balance) disorder. Conversely, the increased incidence of tiptoeing in autistic children does not mean that the majority of children who occasionally tiptoe walk is autistic. The habitual form of tiptoeing is much more common and, unless the child has behavioural problems, there is no reason to suspect that the child is autistic.
There is one form of autism – the Asperger syndrome. Asperger’s syndrome is characterized by difficult social interaction, such as lack of or decreased empathy and lack of understanding of emotional messages such as friends, sadness, anger or resentment. Often a tiptoe is harmless and only occurs temporarily.
In order to exclude more serious neurological or mental causes, the doctor decides on a more or less complex diagnosis on a case-by-case basis. This depends on the age at which the tiptoe occurs, how long it has already lasted or what other symptoms have been noticed. In each case, the doctor will take a close look at the child’s gait pattern.
He examines the anatomy of the foot, ankle and calf. The mobility of the hip and knee joint should also be tested. It is also important to check the child’s sense of balance.
The gait analysis can also be done electronically by capturing reflectors on the skin by many small cameras. In addition, an EMG (electromyogram) measures muscle activity in order to rule out diseases of the nerves or muscles. Here, the foot lifter muscle (Musculus tibialis anterior) in particular is checked for its function.
If cerebral paresis, mental retardation or autism is suspected as the cause, appropriate neurological function tests are performed and mental development is checked. The treatment also depends on the cause of the tiptoe. If the tiptoe walk is due to another disease such as a neuromuscular disorder, clubfoot or autism, the underlying cause should be treated in the best possible way.
If a causal therapy is possible, then tiptoeing will also change into a normal gait pattern. The forms of therapy mentioned here therefore mainly refer to the idiopathic tiptoe gait and forms in which the underlying disease as cause cannot be treated. Almost exclusively pre-school children are affected by tiptoe gait.
In about 50% of the cases, the problem of tiptoeing resolves itself all by itself until the beginning of school. The physiotherapeutic approach includes first of all estimating the severity of the problem. This is done by examining the feet and legs.
Special attention is paid to the mobility of the upper and lower ankle joint, as well as the other large joints of the lower extremity such as knee and hip. It is also important to observe the gait pattern closely and to evaluate it accordingly. About one third of those affected suffer from a shortening of the calf muscles or the Achilles tendon.
This can be eliminated by appropriate physiotherapeutic stretching exercises. In addition, the physiological arch of the foot often flattens in the course of the disease and can be rebuilt by physiotherapy. Children also often tend to fall into a hollow back (lumbar lordosis).
The physiotherapeutic measures then serve in the sense of a posture school to build up strength, e.g. of the back muscles, and to promote mobility. Balance and coordination exercises are also helpful.Regular physiotherapy shows considerable success already after 6 months and can be completed after one to two years. If no success has been achieved despite conservative measures such as physiotherapy, orthoses, plaster casts or splints for the night are available as an alternative to correcting the foot malposition.
If the tiptoe has not grown together in childhood and persists into adulthood, problems with the back, hips and knees are usually caused by the incorrect weight-bearing. Here again different starting points of a physiotherapy arise. Especially the strengthening of the right musculature to compensate for the incorrect posture becomes relevant here.
In physiotherapy, attention is also paid to putting off the learned bad posture and to relearning the physiological gait. This process can be very lengthy, but in the long run it is the only chance to be free of symptoms. In addition to physiotherapy, osteopathic strategies can also be helpful.
The tip-toe gait is often accompanied by limited mobility of other joints, especially the upper ankle joint. In the best case, the osteopath detects this and takes appropriate action to counteract it. Malpositions of the back, for example, can also be treated with the help of osteopathy.
Children who prefer to walk on tiptoe often have difficulty finding their balance in a normal position. In this respect there is a disturbance of the perception of balance. However, this can be trained and optimized with various exercises.
Some children exhibit tiptoeing in situations where they are under great stress, excitement or fatigue. The tiptoe gait is therefore situational in these children. In this context, an attempt can be made to change the perception with regard to such triggering situations and to develop adequate strategies, e.g. against stress.
In some children with tiptoe gait, a correlation to other disorders can be seen. In some cases the children show weaknesses in concentration or other conspicuous behavior. There are specially developed insoles for the therapy of tiptoe, the pyramid insoles according to Pomarino®.
The insoles are individually adapted for each child. The foot is especially supported by these insoles and gets new hold. The material is very resilient, which is especially important for the heavy strain on the forefoot during tip-toe gait.
The insoles not only have a direct positive effect on the foot, but also have an indirect effect on the tendons and muscles. In many cases, the idiopathic clubfoot “grows out” in childhood, even without medical intervention. In any case, the specialized physician (usually an orthopedist) decides when therapy is necessary and when regular check-ups are sufficient.
Special pyramid insoles are often used for early therapy. These are individually adapted to the foot and are intended to force it into a normal position. Physiotherapy and certain stretching exercises can also be used to treat a shortened Achilles tendon.
This treatment of the idiopathic tiptoe walk is completed after about 6 to 24 months and has a very good prognosis. If this does not result in sufficient improvement, an attempt is made to achieve a normal position with the aid of orthoses, plasters or splints. The frequently contracted calf muscle can be relaxed by an injection of botulinum toxin (Botox). A surgical lengthening of the shortened Achilles tendon, on the other hand, is rather rare.