Is Idiopathic Toe Walking Caused by Retained Primitive Reflexes?

Toe walking, also referred to as "tip toe behavior", entails walking on the toes or forefoot, with a lack of heel strike upon initiation of the stance phase of gait. It is believed to occur normally during development of tandem heel-toe gait, but should resolve by 3–7 years of age. Toe walking may occur in three modalities: class 1(in standing, walking and running); class 2 (in walking and running) and class 3 (only during running). The prevalence of toe walking at age 5.5 is 2% in normally developing children, and up to 41% in children with neuropsychiatric diagnosis or developmental delays, with a slight male predominance. The prevalence may be up to one-third in autism spectrum disorders (Valagussa et al 2015). The biomechanical effects of toe walking overlaps with those described in another article on functional hallus limitus.

The exact etiology of ITW remains unknown. Although the majority of toe walkers are otherwise healthy children, it is important to assess each case with a high index of suspicion as toe walking can be due to a structural problem such as a contracted tendon, compensation for a short limb, or a manifestation of autism spectrum disorders, cerebral palsy, muscular dystrophies, or other neurologic or neuromuscular conditions. Toe walking has been associated with speech/language delays, abnormalities in executive functions, social skills, learning, and memory, with differences in motor control, sensory processing, and vibration perception thresholds when compared with adolescents with normal gait. At the cellular level there is an increased concentration of type 1 muscle fibers among toe walkers. Ten to 88% of idiopathic toe walkers have a family history of toe walking with an autosomal dominant inheritance with incomplete expression observed in some families.

Causes of Toe Walking

·         Cerebral palsy

·         Congenital muscular dystrophy

·         Tethered cord syndrome

·         Diastematomyelia

·         Autism

·         Schizophrenia

·         Global developmental delay

·         Charcot-Marie-Tooth disease

·         Spina bifida

·         Transient dystonic reaction

·         Venous malformation of the posterior calf muscle

·         Ankylosing spondylitis

·         Congenital or posttraumatic limb-length discrepancy

Treatments for toe walking include physiotherapy, orthotics, serial casting, chemical denervation, and surgical lengthening of the gastroc– soleus–achilles complex. Recent systematic reviews show good evidence for the use of casting and surgery, with surgical interventions showing the most promising long term results.

So Is Idiopathic Toe Walking Caused by Retained Primitive Reflexes?

Primitive reflexes are a type of neurological soft sign and are associated with many of the conditions noted above to be potential causes of toe walking. There are a family of foot primitive reflexes which have a motor response of plantar flexion. As well, plantar flexion is a motor response of other trunk extension reflexes. The foot tendon guard, plantar grasp and heel grasp are the foot reflexes which most closely reproduce the toe walking pattern.

Although evidence based treatments are noted above, there are always non responders and the treatments can be very inconvenient and / or invasive.

All toe walkers have these reflexes. It is unknown for sure if the reflexes are the cause of toe walking or a secondary manifestation. In any case, the reflexes are easily treated in most infants and children. In some children, the extensor reflexes will need to be treated as well as sensory motor deficits.

Primitive reflex inhibition can provide a conservative option for the treatment of toe walking in children. Parents or caregivers can easily be taught the techniques with monitoring and progression guided by the therapist. 

 Sean GT Gibbons BSc (Hons) PT, MSc Ergonomics, PhD (c), MCPA

References

Babb A, Carlson WO 2008 Idiopathic toe-walking. S D Med. 61(2):53, 55-7.

Dietz F, Khunsree S 2012 Idiopathic toe walking: to treat or not to treat, that is the question. Iowa Orthop J.32:184-8.

Durrant B, Chockalingam N 2009 Functional Hallux Limitus: A Review. Journal of the American Podiatric Medical Association. May/June, Vol 99, No 3. 236-243

Engström P, Tedroff K 2012 The prevalence and course of idiopathic toe-walking in 5-year-old children. Pediatrics. 130(2):279-84. doi: 10.1542/peds.2012-0225. Epub 2012 Jul 23.

Eiff MP, Steiner E, Judkins DZ, Winkler-Prins V 2006 Clinical inquiries. What is the appropriate evaluation and treatment of children who are "toe walkers"? J Fam Pract. 55(5):447, 450.

Oetgen ME, Peden S 2012 Idiopathic toe walking. J Am Acad Orthop Surg. 20(5):292-300. doi: 10.5435/JAAOS-20-05-292.

Ruzbarsky JJ, Scher D, Dodwell E 2016 Toe walking: causes, epidemiology, assessment, and treatment. Curr Opin Pediatr. 28(1):40-6. doi: 10.1097/MOP.0000000000000302.

Sivaramakrishnan S, Seal A 2015 Fifteen-minute consultation: A child with toe walking. Arch Dis Child Educ Pract Ed. 100(5):238-41. doi: 10.1136/archdischild-2014-307852. Epub 2015 Apr 8.

Valagussa G, V. Balatti, L. Trentin, V. Terruzzi and E. Grossi 2015 The Hardness of Standing Support Surfaces Influences Tip-Toe Behavior of Autistic Children: Evidence from a Pilot Study. International society for Autism Research. Salt Lake City, UT, USA May 13-16

Valagussa G, V. Balatti, L. Trentin, S. Melli, M. Norsi and E. Grossi, 2015 Toe Walking and Autism: Cross-Sectional Study on Presentation Patterns and Correlation with Autism Severity. International society for Autism Research. Salt Lake City, UT, USA May 13-16