Eighty children with idiopathic toe walking (ITW) were examined 2-8 years(average, 34 months) after initial presentation to compare outcomes [passive ankle dorsiflexion (DF) and parental satisfaction] after three treatment modalities: observation, cast/brace treatment, or surgical triceps surae lengthening. Overall, 32% had a family history of ITW, 28% were born prematurely, and 16% had psychomotor delay. Forty-eight untreated patients showed little change in passive ankle DF at final follow-up, and only 25% of parents were satisfied with the child's gait. Compared with untreated children, casting/bracing appeared to offer no significant improvement in ankle DF or parental satisfaction. Surgical treatment was performed in 15 children with more severe equinus contractures. Triceps surae lengthening resulted in significantly improved ankle DF and 67% parental satisfaction(p < 0.05). Toe walking may persist after all standard treatment methods even in the absence of significant Achilles contracture.