Saying No To Surgery For Toe Walking In An Active Five Year Old

Jessica is a healthy 5-year-old that was brought in to see our podiatry team due to her tendency to walk on her toes daily for over 80% of the time, which was concerning her parents.

Jessica had seen her GP for this problem, who referred the family to an orthopaedic surgeon for surgery on her Achilles tendons on both feet to help with the problem. Jessica’s parents were not happy with surgery as a first option – and were concerned about the effect this would have on an otherwise very active and playful Jessica, and the potential long-term repercussions a surgery at this age could have on her as she grows.

Idiopathic Toe Walking: Explained

Idiopathic toe walking is the term for toe walking that can’t be explained by or linked to other neurological or orthopaedic problems.

Looking At Jessica’s Gait

When assessing Jessica’s gait, we noticed that her toe walking was not as pronounced as we observed when she first walked into the treatment room. This is something we often see in kids who try to alter the way they walk when in a doctor’s office. As we got her to run, play and perform other activities that took her mind off being ‘assessed’, the toe walking quickly presented. We noticed:

• Difficulty when trying to get the heels to make full ground contact and walk heel-to-toe
• Good knee motion and extension – Jessica’s knee function was not compromised
• Jessica’s foot stayed pointed down (plantarflexed) as she took steps
• Jessica’s toe splayed outwards to give her a larger base of gait for stability when walking – explaining some of the redness and rubbing on the outer edges of the feet as her splayed foot width didn’t fit into her shoes comfortably

It was easy to identify that it was the muscle contracture that was really limiting Jessica. We agreed that treatment could be achieved without any surgery.

Jessica’s Treatment

Jessica’s treatment plan was carefully discussed with her parents – who would be integral to her successful outcome. We would use:

• Achilles tendon/gastroc complex stretching and ankle dorsiflexion (pointing the foot upwards) strengthening exercises. Jessica’s parents needed to assist with this stretching, both spending time with her to do the stretches and helping her complete the stretches
• Articulated ankle-foot orthoses (AFO’s) for day-wear with mechanisms that help prevent and discourage the foot from pointing downwards. Due to Jessica’s age, her parents preferred this option as opposed to serial casting, which is an option where the age or compliance to wear the AFO is in question
• Night splints
• Supportive footwear with a rigid sole and straight last that was wide enough to not add to the rubbing on the sides of Jessica’s feet, while helping fit the AFO’s

Regular affirmation and reinforcement of Jessica’s altered heel-to-toe walking pattern by her parents was also an important part of the process.

Within the first six weeks, Jessica’s parents noticed a marked improvement in the movement available at her ankle – and her ability to point her foot upwards. Over the first three months, a heel-to-toe walking pattern became the norm for Jessica as it was now significantly more comfortable to walk this way without pain, tightness or discomfort in her calves.

Jessica was able to stop wearing the AFO after 12 weeks, continuing with the stretching and night splints. Since then, her walking pattern has dramatically improved and her parents have confirmed that she has stopped toe-walking.