Introduction

Toe walking is a pattern of gait where an individual walks on the tips of their feet, without letting their heels touch the ground.¹ It is commonly observed in young children who learn to walk, and this habit resolves naturally as they develop a mature form of gait. However, persistent toe walking can be classified as habitual or pathological. It is often linked to neurological, muscular, or orthopaedic disorders. This article aims to outline the neurological causes of toe walking, as it allows identification of underlying issues for early intervention. Methods geared towards prevention can help improve mobility, prevent complications, and improve overall quality of life for individuals affected with various associated conditions (such as cerebral palsy, muscular dystrophy or autism spectrum disorder).² Proper assessment, treatment and management are precursors to addressing gait abnormality

Neurological conditions associated with toe walking

Cerebral palsy

Cerebral Palsy is a common neurological condition resulting from brain injury or abnormal development, which affects movement and muscle control. A primary indicator of cerebral palsy, which is spasticity, leads to increased muscle tone and stiffness in the lower limbs. This symptom affects various calf muscles, causing a child to walk on their toes (due to limited ankle dorsiflexion). As the habit continues, toe walking further restricts normal gait development.³

In a subtype of cerebral palsy, spastic diplegia, both legs are primarily affected, where calves and hamstrings have increased tone. This causes difficulty in touching heels to the ground, leading to a scissoring gait. In spastic hemiplegia, another subtype, only one side of the body is affected; this leads to asymmetric gait patterns with only one side’s leg demonstrates toe walking.⁴ Comprehensive and early interventions in electrical stimulation,⁵ physiotherapy, and surgery may help improve mobility and reduce complications from toe-walking.

Autism spectrum disorder

Toe walking is also observed in children with autism spectrum disorder, an experience of difficulty in sensory processing, which influences movement patterns. ASD causing toe walking is idiopathic in nature, meaning there is no identifiable structural or neuromuscular cause for toe walking.  Children diagnosed with ASD may express repetitive behaviours; affected movement patterns include toe-walking. Left unaddressed, toe-walking leads to muscle tightness, contractures and balance issues.⁶

Children with ASD often present with issues of sensitivity to textures – in hypersensitivity, children often try to walk on their toes to minimise any sensory input from textures on the ground. Alternatively, , hyposensitivity means a child seeks additional proprioceptive input and walks on their toes to enhance their sense of position. 7 A major challenge to toe-walking also includes dyspraxia, difficulty in motor planning. This makes it challenging for children to coordinate smooth, heel-to-toe walking.⁸
A combination of sensory integration and physiotherapy, and interventions such as serial casting help children correct their gait and posture, and limit long-term difficulties in movement.

Muscular dystrophy

Muscular Dystrophy represents a group of genetic disorders that cause progressive muscle weakness and degeneration. Toe walking in such conditions primarily results from weakness in lower limb muscles, and with disease progression, children develop compensatory toe-walking habits due to weak muscles, hoping to maintain mobility.

In Duchenne Muscular Dystrophy  (a common form of muscular dystrophy), children often develop a condition called calf muscle pseudohypertrophy, where muscles appear enlarged, but are actually weak. This typically causes toe-walking behaviours in children,⁹ commonly occurring around ages 2 to 5, when children further develop a waddling gait, frequent falls and struggle with tasks like climbing stairs. A combination of physical therapy, steroid treatments and assistive devices such as casts or wheelchairs helps improve mobility, manage symptoms and aid in appropriate walking.

Charcot-marie-tooth disease

Charcot-Marie-Tooth disease is a set of peripheral neuropathies resulting in progressive damage to the nerves responsible for controlling lower limb and foot muscles. This leads to muscle weakness, sensory loss, and deformities of the foot such as high arches and curled toes. Resulting structural abnormalities cause individuals to walk on their toes & develop a steppage gait to compensate for foot drop.¹⁰

This combination of lower limb weakness and sensory loss affects balance and coordination. Toe walking in CMT can be a compensatory mechanism to maintain stability due to weakened ankle dorsiflexors, which progress over time.

Spinal cord abnormalities

Abnormalities in spinal cord development, such as tethered cord syndrome and spina bifida, cause significant neuromuscular dysfunction that impairs one’s ability to walk. In Tethered cord syndrome, the spinal cord is abnormally attached to surrounding tissues, sensory loss, leading to progressive weakness, and muscle tightness in the lower limbs.¹¹ Similarly, spina bifida is a congenital neural tube defect resulting in varying degrees and severities of paralysis, which contribute to muscle imbalance, toe walking and other gait abnormalities.¹²

Toe walking is an early sign of an underlying spinal cord abnormality, especially when accompanied by asymmetry or bladder and bowel dysfunction. Early diagnosis through neurological assessments and neuroimaging may help detect the severity of spinal cord dysfunction, and interventions comprising surgical detethering and orthopaedic management help improve outcomes.  

Other neurological and genetic conditions 

Other genetic and neurological conditions such as hereditary spastic paraplegia, Rett syndrome or mitochondrial diseases may result in toe-walking. In hereditary spastic paraplegia (characterised by spasticity and weakness in lower limbs), toe-walking occurs due to tightness in calf muscles.¹³ Rett syndrome is a neurodevelopmental disorder primarily affecting females, resulting in abnormal gait patterns such as toe walking.¹⁴ Leukodystrophies may also result in neuromuscular dysfunction and call for a thorough diagnosis, assessment and treatment plan.¹⁵

Diagnosis and evaluation  

To diagnose and evaluate toe walking, calls for a thorough process to identify the underlying cause of gait abnormalities – involving a comprehensive clinical and neurological disorder (onset and duration of symptoms, family history of genetic or neuromuscular disorders, meeting developmental milestones, prior injuries, and symptoms of pain, weakness, sensory issues and stiffness.)

Next, it is important to undertake a detailed physical, neurological and musculoskeletal assessment, such as muscle tone, strength, reflex, motion and flexibility assessments to identify spasticity, rigidity and/or dystonia. Usually, physicians rely on video assessment of walking patterns such as step length, symmetry and heel strike.¹⁷

Along with clinical assessments, diagnosticians utilise tools such as MRI, EMG and genetic testing to identify structural and functional abnormalities associated with toe-walking. MRI helps assess spinal cord and brain integrity, whereas EMG evaluates muscle activity and nerve conduction. Using motion capture technology and force plates,¹⁸ clinicians obtain a comprehensive assessment of walking patterns to identify and treat specific symptom-oriented conditions and provide holistic care.

Treatment and management 

Effective treatment consists of a variety of treatments to address mobility, function and long-term management. Physical and occupational therapy, comprising stretching and strengthening exerciseshelp maintain flexibility and muscle strength, reducing the risk of contractures and improving movement patterns.  Sensory integration therapy is beneficial for individuals with ASD, to improve the brain’s vestibular processing capabilities, reducing abnormal gait patterns. ¹⁸

Additionally, assistive devices and orthotic devices help provide structural support to enhance the efficiency of walking. Ankle foot orthoses (AFOs) help stabilise the ankle, promote heel strike and prevent plantar flexion. Shoe modifications such as heel lifts help reduce strain in the lower extremities. ¹⁹

Alternative treatments are implemented in cases where a patient does not respond well to conservative treatments. Overactive muscles that spasm and restrict movement can be relaxed through interventions like botulinum injections.²⁰ In some cases, where contractures persist, tendon lengthening surgeries are done to correct and enhance walking patterns.

Multidisciplinary and comprehensive treatments are the most effective approach when dealing with a patient’s underlying condition. The value brought by the integration of physicians, orthopaedic doctors, physical therapists, and occupational therapists who specialise in rehabilitation results in better care for the patient. Active participation of the patient and caregiver is also very important to increase the success of the treatment. With this approach, patients can function much better and improve their everyday life substantially.

Conclusion

Early recognition aids early intervention in the cases of toe-walking, ensuring optimal outcomes, especially in times of neurological comorbidities. Implementing timely assessments and targeted treatments, care can be extended to reduce or prevent complications such as impaired mobility or muscle contractures.

A team of specialists, like neurologists, physiotherapists, orthopaedic surgeons, etc., play a crucial role in providing comprehensive and tailored care with regard to the patient’s needs. Additionally, research into techniques in physiotherapy and neuromodulation, gait analysis and robotic-assisted therapies also shows great promise in addressing toe walking as a symptom of neurological dysfunction. By fostering continued research and collaboration between various medical and scientific fields, clinical research may help advance our understanding about the disease aetiology, treatment and quality of life considerations