August 2017

ITW update: Etiological clues, collaborative care

Photo courtesy of Surestep

Researchers still haven’t unraveled the ‘I’ in ITW, or idiopathic toe walking, but studies continue to point to neurodevelopmental  and genetic links. Here, we review recent literature and experts explain how they assess patients’ history and biomechanics for information to guide treatment.

By Larry Hand

What’s the best way to manage pediatric patients with idiopathic toe walking (ITW)? That remains the question as too few researchers delve into why some children develop ITW and some don’t.

“There’s just little information out there on efficacies of treatments,” Kevin C. Matthews, CO/LO, of Advanced Orthopedic Designs, San Antonio, TX, told LER: Pediatrics. “It’s an area that deserves further study. Hopefully, someone will do a [retrospective] study of different treatments and long-term outcomes, and whether parents were satisfied with the care received.”

Although some research has trickled in since LER: Pediatrics last covered the topic in 2014 (See “Toe walking researchers revisit idiopathic label,” November 2014, page 15), evidence on the efficacy of ITW treatments, from physical therapy to surgery, is still lacking. One barrier is that the cause of much toe walking is still unknown.

“The “I” is the most pressing need [in ITW research today]. The condition needs to move beyond the idiopathic status,” said Mark Geil, PhD, chair of the Department of Kinesiology and Health and director of the Center for Pediatric Locomotion Sciences at Georgia State University in Atlanta. “Our treatments are attempting to control a problem without knowing the cause. We’re treating symptoms.”

In response, some researchers are boring into potential neuro­developmental issues.

In a study published in 2016 in Neurologia,1 researchers suggested ITW as a potential marker of neurodevelopmental impairment. Researchers compared neurodevelopmental characteristics, ITW risk factors, and scores on the Child Neuropsychological Maturity Questionnaire (CUMANIN) between a group of 56 children with ITW aged 3 to 6 years and an age-matched 40-child control group.

The percentage of patients with a family history and biological risk factors was higher in the ITW group, and parents of ITW patients reported significantly poorer motor coordination in their children. These patients also scored significantly lower on CUMANIN subscales of memory and psychomotricity, as well as on verbal, nonverbal, and overall development.

“At this moment, only well-known pathologies [such as cerebral palsy or neuromuscular dystrophia] are considered as a neurological diagnosis. These pathologies are clearly diagnosed by means of specific neuroimaging or laboratory evaluations,” said study first author Patricia Martín-Casas, PhD, coordinator of physiotherapy at the Complutense University of Madrid in Spain.

“But some authors, and also our investigation team, consider also the possibility of a nondiagnosed minimal cerebral dysfunction causing toe walking in some cases,” she continued. “This can only be diagnosed by [methods] such as functional magnetic resonance imaging, not easily used, or by clinical evaluation with specific tests or questionnaires, such as CUMANIN.”

“Kids who don’t outgrow ITW may face serial casting and surgery when the condition should be treatable earlier, at a more fundamental level.” —Mark Geil, PhD

ITW has also been linked with language disorders and autism,2 and recently with attention deficit disorder and hyperactivity (ADHD). A study from Spain, published in July in Anales de Pediatria, noted a high frequency of ITW in children with ADHD.3 Of the 312 children (mean age 11 years) 20.8% had ITW and 49.2% (32) of those had Achilles tendon shortening. The researchers found significant associations between having ITW and sociability disorders, absence of pain in the legs, and a family history of ITW.

Martín-Casas’ research and that of others has led her to expand her objective evaluation of children with ITW, she said, noting she’s heightened her focus in physiotherapy treatment on developmental problems and multisensory integration. She also advocates bringing together different disciplines for the best outcomes.

A case study presented last year at the Association of Children’s Prosthetic-Orthotic Clinics annual meeting outlined the benefits of pairing the expertise of a physical therapist with that of an orthotist in the treatment of a kindergarten-age boy with ITW and severe equinus contractures.4 At the start of treatment his dorsiflexion range of motion (DF-ROM) was -40º bilaterally and he could walk only on his toes.

Treatment over about eight months included bilateral ankle foot orthoses, shoes modified with 35º heel wedges, and serial casting. The physical therapist and orthotist assessed him every other week, and the orthotist adjusted the wedges every two to four weeks, decreasing them by 5º to 10º, and increasing the dorsiflexion angle. After six months, the boy had increased stability and could run, stand on one foot, and skip. His DF-ROM increased to -15º on the right side and -25º on the left. He then underwent seven weeks of serial casting; his DF-ROM improved to 0º on the right side and -3º on the left, and he could walk heel to toe with and without orthoses and could run and jump.4

“I would like to [call] for a real multidisciplinary approach to these children, as toe walking is a sign of many present and future difficulties,” Martín-Casas said.

Diagnosis through exclusion

“An assessment of the biomechanics of the foot and leg is fundamental, and health professionals must also exclude any neurological causes of toe walking gait through extensive assessment and history taking,” Cylie M. Williams, PhD, senior research fellow in physiotherapy at Monash University in Australia, told LER: Pediatrics by email. “This includes questions about family history of neurological conditions, identifying any risk factors from prenatal and postnatal trauma, or identifying developmental concerns.”

In a study published last year,5 Williams and colleagues studied birth characteristics in a population of 95 children with ITW (mean age 5.8 years). Children with ITW had greater rates of prematurity and admission to a special care nursery or neonatal intensive care unit, as well as lower birth weights, compared with normative children included in Australian perinatal statistical data.

In a German study, also published in 2016,6 researchers tested clinical examination methods designed to evaluate ITW in 836 children. Children with ITW and a positive family predisposition had more severe cases of toe walking than children with ITW and no family history.

“Where there is any red flag for a neurological reason, a health professional should refer the child for further assessment from someone with more extensive experience,” Williams said.

Varied paths to treatment

Treatment for ITW is varied, Williams said, and it should proceed even without a lot of evidence.

“There are many treatments being used to treat idiopathic toe walking. These may include orthotics, motor planning, even stretches, that have limited evidence to support being recommended,” she said. “We need to remember that no evidence should not be confused with lack of evidence. Just because there is a lack of evidence, it doesn’t mean things should not be used.”

Botulinum toxin A (Botox) is one treatment that has been tried with mixed results.7 In a recent randomized controlled trial in Finland,8 for example, researchers evaluated whether adding Botox to conservative treatment enhanced the ability of toe-walking children aged 2 to 9 years to walk normally. Two years after treatment, the injections hadn’t significantly improved children’s ability to walk with a flat foot or with a heel strike.

In a study9 of another proposed treatment, Williams and colleagues found whole body vibration was associated with immediate improvement in heel contact and ankle ROM in children with ITW aged 4 to 10 years. Benefits, however, were not sustained longer than 20 minutes postintervention.

She noted other approaches involve ankle foot orthoses (AFOs) combined with modified footwear or full-length carbon-fiber footplates or orthoses.

“These work through slightly different mechanisms, but the aim is to limit the child going up on their tiptoes,” Williams said. “It is reasonable to think that in the long term, this may have some motor planning impact and may reduce any ankle equinus. However, the long-term success is unknown. The choice between the different types of orthotics appears to be based on knowledge, access, and preference of the health professional.”

She stresses the importance of providers being clear in their communications with parents about the understood efficacy of various treatments.

“Health professionals need to ensure they don’t create a level of expected outcomes that may not be achieved. Where there is a financial investment by parents in dollars and time, health professionals must ensure parents understand their options,” she said.

Decision making

Matthews takes a practical approach to evaluating first-time patients.

“As long as a child doesn’t have abnormal tone—meaning it’s simply idiopathic toe walking and not cerebral palsy or something like that—I basically evaluate the range of motion, and if I’m able to achieve at least ten degrees of dorsiflexion through passive range of motion, then they’re a candidate for bracing,” he explained. “If they have adequate range of motion, then I’ll put them in a brace with a plantar flexion stop.”

Geil and Herrin found that a foot orthosis with attached rigid carbon-fiber footplate (left) didn’t control ITW as well as an articulated AFO (right); the less-restrictive device, however, was better accepted by children and their parents, and had similar out-of-brace effects. (Photos courtesy of Kinsey Herrin, MSPO, LPO, CPO.)

Louis J. DeCaro, DPM, a pediatric specialist in Massachusetts and president of the American College of Foot and Ankle Pediatrics, has a three-component process for making treatment decisions.

“Number one is history,” he said. “The history should include questions that are focused on neurological concerns as well as sensory processing disorders. The second component of the exam is to measure the equinus of the patient correctly. A lot of times equinus measurement is not done correctly.”

The third component is a gait study, paying close attention to vision.

“You can change the field of vision of the patient and see if that affects the toe walking, as well as looking at the foot type and seeing if the patient is toe walking because of compensatory measures for forefoot biomechanics,” DeCaro said.

“Toe walking is either from neuromuscular issues, equinus,
vision, or forefoot varus that’s premature, where the patient has to come up on their toes for balance, or just general weakness of the body and the patient has to come up on their toes,” he added. “If the reason for toe walking is forefoot varus, orthotics can be very effective.”

They may also assist with sensory processing, he said. “If you’re trying to train the brain to [help the heel] come down, you can put a full carbon-fiber plate extension on the orthotic, as well if they’re coming up on their toes because of the amount of pronation or abduction or forefoot varus.”

Orthoses: Which one?

Sometimes selecting a proper orthosis can be a real process.

Georgia State’s Mark Geil and Kinsey Herrin, MSPO, LPO, CPO, of Ortho Pro Associates in Miami, FL, conducted a nonblinded randomized trial10 comparing the effects of an articulated AFO versus a rigid carbon-fiber footplate attached to a custom foot orthosis with attached rigid carbon-fiber footplate attached to a cork base, layered with 1/8″ Poron and 1/8″ ethylene vinyl acetate.

Participants completed a 3D gait assessment and the L-test of Functional Mobility at baseline and after six weeks of treatment. Both groups significantly improved in heel-rise time compared with baseline, but when the orthoses came off, the orthosis group sustained improvements, while the AFO group did not.

“Both groups showed improvement versus baseline. The difference we observed was that the AFO group showed more improvement in-brace—the AFOs were one-hundred percent effective at preventing initial contact with the toe—but some of that improvement was lost when the brace was removed. That’s important, because for these kids the orthosis is meant to be a short-term corrective treatment, not a permanent addition,” Geil said.

“I think the difference in response was that, while the AFO provided excellent correction when worn, it was more restrictive than the foot orthosis, and once removed the children regressed a bit to the gait pattern they still preferred,” he said. “The foot orthosis might have been providing more of a reminder to alter that pattern than complete control of the pattern.”

Geil noted the six-week time frame was not ideal, but imposed by funding and other issues.

“It would make sense to assess the children over the duration of orthotic treatment,” he said. “However, that time span might have drawbacks, as well. For example, we had one child who was ‘fighting’ the orthosis so much that he’d worn out the sole of his shoe by the end of our six-week trial. We believe that treatments for these children might need to be individualized quite a bit, so if a child is randomized into a treatment that doesn’t match her needs, a long-term trial won’t work.”

Going forward

Said Matthews, “With idiopathic toe walking, there is no causal diagnosis, they just walk on their toes. If they’re three or four years old or older when they start toe walking, that’s an indicator that something else may be going on,11 and diagnostics to rule out neurologic issues should be pursued.”

Williams, in Australia, said she hasn’t changed very much in her treatment strategies, but she has “dramatically” changed her way of communicating.

“I feel I present a bigger picture of options but try not to overwhelm. When children with ITW also have extensive ankle equinus, I used to be less inclined to present surgical treatment as an option, preferring instead to steer them to serial casting. Now I present all options as equally viable, as in the absence of an effectiveness trial, we don’t know if surgery is more or less effective than casting,” she said, adding that the two treatments have different costs and timeframes that could lead parents to choose one over the other.

For mild equinus, some parents may opt for stretching exercises and a wait-and-see approach, Williams said. “Others may prefer balance work, exercises promoting weight shift, or use of orthotics in boots [conventional, heavy boots with a flat sole and minimal toe kick that accommodate a full-length orthosis].”

Williams has a personal story. “It is difficult when you get the ‘What would you do?’ question. I’m the mother of a [child] who has been diagnosed with idiopathic toe walking. I get where they are, because as a family, we’ve been on the other end of it, but what I do is what works for my family. Even with all this knowledge, my 184-cm adolescent still toe walks at times but has no equinus. I’ve almost tried every strategy under the sun, but I feel like I’m winning if we’ve minimized long-term impact.”

Williams and colleagues are currently conducting a survey of healthcare providers on ITW treatment strategies. Take the survey at

Geil offered, “We also need better epidemiology. The numbers in the literature are all over the place. I believe the condition is more prevalent than many realize, and causes substantial long-term issues.”

Studies have reported an ITW prevalence ranging from 7% to 24% in pediatric populations,12 while a large 2012 Swedish study found a prevalence of 4.9% in children aged 5.5 years.13 A 2016 literature review found a 2% prevalence in normally developing children aged 5.5 years and a 41% prevalence in children of the same age with a neuropsychiatric diagnosis or developmental delay.14

Geil offered this reflection on ITW.

“The comments from a single reviewer on one of my NIH proposals were telling. The criticism was not of the idea for the research, but for the very notion of studying this population. Essentially, the reviewer said, ‘Why study these children? They’ll just grow out of it.’ Many do, but the ones who don’t could face difficult serial casting and even surgery for a condition that should be treatable at a more fundamental level, and much earlier.”

Larry Hand is a freelance writer in Massachusetts.


1. Martín-Casas P, Ballestero-Perez R, Meneses-Monroy A, et al. Neurodevelopment in preschool idiopathic toe-walkers. Neurologia 2016 April 14. [Epub ahead of print]

2. Barrow WJ, Jaworski M, Accardo PJ. Persistent toe walking in autism. J Child Neurol 2011;26(5):619-621

3. Soto Insuga V, Moreno Vinués B, Losada Del Pozo R, et al. [Do children with attention deficit and hyperactivity disorder (ADHD) have a different gait pattern? Relationship between idiopathic toe-walking and ADHD]. An Pediatr 2017 Jul 10. [Epub ahead of print]

4. Harris NM. Multidisciplinary approach led to positive results for pediatric patient with idiopathic toe walking. Presented at the Association of Children’s Prosthetic-Orthotic Clinics Annual Meeting, Broomfield, CO, April 15, 2016.

5. Baber S, Michalitsis J, Fahey M, et al. A comparison of birth characteristics of idiopathic toe walking and toe walking gait due to medical reasons. J Pediatr 2016;171:290-293.

6. Pomarino D, Ramirez Llamas J, Pomarino A. Idiopathic toe walking: tests and family predisposition. Foot Ankle Spec 2016;9(4):301-306.

7. van Kuijik AA, Kosters R, Vugts M, Geurts ACH. Treatment for idiopathic toe walking: A systematic review of the literature. J Rehab Med 2014;46(10):945-957.

8. Satila H, Bellmann A, Olsen P, et al. Does botulinum toxin A treatment enhance the walking pattern in idiopathic toe walking? Neuropediatrics 2016;47(3):162-168.

9. Williams CM, Michalitsis J, Murphy AT, et al. Whole-body vibration results in short-term improvement in the gait of children with idiopathic toe walking. J Child Neurol 2016;31(9):1143-1149.

10. Herrin K, Geil M. A comparison of orthoses in the treatment of idiopathic toe walking: a randomized controlled trial. Prosthet Orthot Int 2016;40(2):262-269.

11. Engström P, Tedroff K. The prevalence and course of idiopathic toe-walking in 5-year-old children. Pediatrics. 2012;130(2):279-284.

12. Engelbert R, Gorter JW, Uiterwaal C, et al. Idiopathic toe-walking in children, adolescents and young adults: a matter of local or generalised stiffness? BMC Musculoskelet Disord. 2011;12:61.

13. Engström P, Tedroff K. The prevalence and course of idiopathic toe-walking in 5-year-old children. Pediatrics 2012;130(2):279-284.

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