Definition
- Persistent toe walking beyond age 3 without neurological or orthopaedic cause is idiopathic toe walking
- Diagnosis of exclusion
Aetiology
- Idiopathic, often with family history
- Secondary causes are CP, DMD, CMT, tethered cord and autism spectrum disorder
- Unilateral toe walking suggests leg length discrepancy, hemiplegia or hip pathology
Epidemiology
- Toe walking is normal in early walkers up to about 2 to 3 years
Clinical Features
- Child with idiopathic toe walking can walk heel to toe on request
- Reduced ankle dorsiflexion with knee extended indicates gastrocsoleus contracture
- Silfverskiöld test separates gastrocnemius from soleus tightness
- Check Gowers sign and calf pseudohypertrophy for DMD
- Check tone, reflexes, clonus, sensation and spine
- Screen development, speech and social communication
Investigations
- CK in boys to exclude DMD
- MRI spine and nerve conduction when neurological signs present
- Gait analysis when diagnosis uncertain
Differential Diagnosis
- Spastic diplegia
- Muscular dystrophy
- Hereditary motor sensory neuropathy
- Residual clubfoot equinus
Management
- Observation when ankle dorsiflexes past neutral
- Stretching, physiotherapy and night AFO
- Serial casting for fixed equinus, with or without botulinum toxin
- Gastrocnemius recession (Strayer or Baumann) for persistent gastrocnemius contracture
- Tendo Achillis lengthening for combined gastrocsoleus contracture
- Surgery usually reserved for children over 5 years
Prognosis
- Most idiopathic toe walking resolves spontaneously by age 10
- Recurrence after casting is common
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.