pediatrics

Treatment options for children’s toe walking

Many children will walk on their toes when they learn to walk and most will grow out of that pattern.

But toe walking out of habit, also known as idiopathic toe walking, can become a problem if not treated.

Dr. David J. Anderson, an orthopedic surgeon for Signature Medical Group, said the goal to treating idiopathic toe walking is to regain full flexibility of the Achilles tendon and calf muscles, and then to maintain that range of motion while the child grows and the tendency for toe walking abates.

Dr. Anderson suggests several methods of treatment depending on the child:

Daytime and nightime bracing. Hinged plastic AFO braces are custom-made for both legs.  In the daytime, the brace prevents toe walking; at night, the brace is used as a stretch splint.  Treatment is for a minimum of six months, at which point the child is reassessed and a decision is made whether continued bracing is needed.  Some children wear the braces for up to two years.

Serial casting. Short-leg fiberglass walking casts are applied to both legs with the ankle in the most stretched position easily attainable at the time of casting.  The casts are applied in the doctor’s office with the child awake.  Care is taken to avoid extreme stretching, which may cause painful muscle spasms or skin pressure sores inside the casts.  The child walks in the casts immediately.  The casts are changed every 7-10 days in the office, with each subsequent cast providing more stretch than the previous one.

With this method, gradual stretching of the Achilles tendon and calf muscles is achieved over a three-week period.  Waterproof casts may be an option for some patients. If not, the casts must be kept dry at all times.

When the casts are removed for the final time,  the young patients are fitted with arch supports to be used in their tennis shoes during daytime until they outgrow the toe walking tendency, and a night-stretching AFO is used for six months.

Botox injection. Botox (Botulinum-A toxin) is a medicine frequently used in children with tight muscles from a variety of causes.  In the case of toe walking, the two major calf muscles (gastrocnemius and soleus) are injected with Botox in the operating room with the child under a brief general anesthetic.  Four injections are typically made in each leg, for a total of eight injections; most children would not tolerate this well in a doctor’s office, so they are done with them asleep.  The procedure lasts about 15 minutes, and they are sent home afterward.

One week later, the serial casting treatment is begun in the office (see above).  Having weakened the calf muscles with Botox often makes the casting process easier and more effective.  Botox works for about four months in the average patient, after which the effect wears off.  If needed, the injections can be repeated every six months.

Unfortunately, most insurance plans do not cover Botox injections for toe walking.  Since the out-of-pocket cost for Botox used for treatment is prohibitive, this option is not practical for most families.

Surgery. Surgical lengthening of the Achilles tendon or higher up in the calf muscle can be performed to treat toe walking.  The procedure is done under general anesthesia as an outpatient, and the child wears walking casts for three weeks after the surgery.  When the casts are removed, an arch support is placed in the shoes and night stretching AFO’s are used for six months, just as with the serial casting treatment.

Dr. Anderson usually recommends surgery only for patients with extremely severe toe walking, or for patients who have not improved with one of the other methods described above.

With persistence, the vast majority of toe walkers can be successfully treated, Dr. Anderson says.

If you’re concerned about your child’s toe walking, make an appointment with a Signature Medical Group orthopedic doctor today.