Toe walking

Disclaimer

These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

Introduction

Toe walking can be a normal variant in young child learning to walk. Most children cease toe walking by the age of 2 years of age.

Of those continuing to toe walk after 2 years of age most will be idiopathic however conditions such as leg length discrepancy, developmental dysplasia of the hip, previous trauma or infection, muscular dystrophies, cerebral palsy, autism spectrum disorder and other orthopaedic, neurological and developmental conditions need to be considered.

Pre-referral investigations

Medical history including prenatal and birth history, development history, history of trauma or infection to the lower limbs.
Details of toe walking – age of onset, intermittent or continuous, is the child able to place the foot flat, is toe walking bilateral or unilateral.
Neurological assessment
Physical examination reviewing spine and calf length/size.
Spinal and hip x-ray if there are concerns.

Pre-referral management

Provide reassurance, most toe walking is idiopathic. Provide education on basic calf stretches.

When to refer

Condition	Refer to
Unilateral toe walking	Orthopaedics department with attached pelvic X-ray report
Bilateral toe walking in child aged over 6 years	Orthopaedics department
Bilateral toe walking in child under 6 years of age	Child Development Service for physiotherapy
Concerns of a medical cause of toe walking	Paediatrician for review
Concerns of a developmental issue causing toe walking (such as autism spectrum disorder or developmental delay)	Public or Private Paediatrician. Please note PCH only conduct developmental assessments in specific circumstances, consider other providers such as CDS or WACHS (see below).

How to refer

Routine non-urgent referrals from a GP or a Consultant are made via the Central Referral Service
Routine non-urgent referrals from private hospitals are made via the PCH Referral Office
Urgent referrals (less than seven days) are made via the PCH Referral Office. Please call PCH Switch on 6456 2222 to discuss referral with the relevant speciality registrar.

Essential information to include

Medical and surgical history including any injuries to lower limbs.
Prenatal and birth history if developmental concerns.
Details of toe walking – onset, frequency, unilateral or bilateral, how far can child dorsiflex, can child stand with heels down
Results of physical exam.
X-ray report if performed (Unilateral toe walking must have a pelvic X-ray prior to referral).

References

Bennett JF, Omura J. Toe Walking. Physician Assistant Clinics. 2020;5(4):477-85.
Bishop C. Evaluation of Pediatric Toe Walking. Physician Assistant Clinics. 2016;1(4):599-613.
American Academy of Orthopaedic Surgeons. Toe Walking [Webpage]. American Academy of Orthopaedic Surgeons,; 2017 [cited 2021 May]. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/toe-walking/.

Reviewer/Team:	Department of Orthopaedics	Last reviewed:	Nov 2021
		Next review date:	Nov 2024
Endorsed by:	Dr Kate Stannage, PCH	Date:	Nov 2021

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