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Commentary and Perspective

Does Idiopathic Toe-Walking Spontaneously Correct?

Commentary on an article by Pähr Engström, MD, PhD, and Kristina Tedroff, MD, PhD: “Idiopathic Toe-Walking: Prevalence and Natural History from Birth to Ten Years of Age”

Reinker, Kent Alan MD*,a

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The Journal of Bone and Joint Surgery: April 18, 2018 - Volume 100 - Issue 8 - p e53
doi: 10.2106/JBJS.17.01408
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Commentary

Idiopathic toe-walking is a relatively common gait disorder of childhood but is quite rare in adults. Thus, it is clear that most idiopathic toe-walking cases are either treated adequately in childhood or spontaneously resolve. About half of the cases resolve by the age of 5 or 6 years, but less is known with regard to resolution in those whose idiopathic toe-walking persists beyond the age of 6 years. This study addresses our deficit in knowledge with regard to idiopathic toe-walking that has persisted into middle childhood. Can some of these individuals still resolve spontaneously? If not, do they require surgical treatment?

We also know that idiopathic toe-walking is frequently seen in children with autism spectrum disorder and other neurodevelopmental challenges not traditionally considered to have a motor component. Many of these, for example, attention deficit hyperactivity disorder (ADHD), tend to be diagnosed only after the child has begun school. Two questions thus arise. The first is whether the toe-walking in those with such a disorder differs from the toe-walking in those who have no such problem. A corollary question is whether treatment of idiopathic toe-walking in a child with a late diagnosis of a cognitive disorder should change as a result of the diagnosis. This study by Engström and Tedroff provides information with regard to both questions.

The authors report that 6 of the 26 neurologically normal children with idiopathic toe-walking at the age of 5.5 years spontaneously resolved by the age of 8 years and another 7 children resolved by the age of 10 years. Thus, of the 63 children who were toe-walking at the age of 2 years, 37 (59%) had resolved by the age of 5.5 years, 43 (68%) had resolved by the age of 8 years, and 50 (79%) had resolved by the age of 10 years. Five had required surgical treatment, 4 before the age of 8 years and 1 afterward.

Of the original 7 toe-walkers with neurodevelopmental disorders, 3 had stopped toe-walking before the age of 5.5 years and 2 more had stopped toe-walking by the age of 10 years. Thus, 5 (71%) of 7 patients had resolved by the age of 10 years, not too dissimilar from the results in the normal patients. However, if the 10 patients with a late neurologic diagnosis are added to the neurodevelopment group and are subtracted from the normal group, spontaneous correction is seen in 85% of the normal patients and only 59% of the neurodevelopmental group, suggesting a worse prognosis in this group.

We have little information with regard to what happens with children with persistent idiopathic toe-walking during the growth spurt of adolescence. Can spontaneous resolution still occur in some patients? Or should we expect an increase in gastrocnemius-soleus complex contracture with the increased growth velocity of adolescence? We simply do not know.

One weakness of this study is the lack of formal gait analysis in a gait laboratory in determining whether the idiopathic toe-walking had resolved. Using gait analysis, Stott et al.1 documented kinematic abnormalities in 12 of 13 mature patients with resolved idiopathic toe-walking, but the changes were detectable visually in only 3 subjects. In addition, O’Sullivan and O’Brien reviewed 102 subjects with presumed idiopathic toe-walking2. Gait analysis was believed to be consistent with the diagnosis in only 81 (79.4%) of the cases, with 21 (20.6%) being atypical, most showing signs of spasticity. These results call into question both the accuracy of diagnosis of idiopathic toe-walking in the current study by Engström and Tedroff and the certainty of resolution.

This study also offers little information with regard to the efficacy and timing of treatment. Other studies have questioned the long-term value of most nonoperative modalities, including physical therapy, botulinum toxin, serial casting, and orthoses3. Surgical treatment has been shown to be effective4, but we have little information about the optimal timing of the surgical procedure, the specific method of lengthening of the gastrocnemius-soleus complex, or the strength or functionality of the gastrocnemius-soleus complex following lengthening in idiopathic toe-walking.

To fill the gaps noted above, I encourage the authors to follow these children until skeletal maturity and to do a final evaluation at that time using state-of-the-art gait analysis.

*Disclosure: There was no source of external funding for this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, the author checked “yes” to indicate that he had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/E711).

References

1. Stott NS, Walt SE, Lobb GA, Reynolds N, Nicol RO. Treatment for idiopathic toe-walking: results at skeletal maturity. J Pediatr Orthop. 2004 Jan-Feb;24(1):63-9.
2. O’Sullivan R, O’Brien T. Idiopathic toe walking: a gait laboratory review. Ir Med J. 2015 Jul-Aug;108(7):214-6.
3. Eastwood DM, Menelaus MB, Dickens DR, Broughton NS, Cole WG. Idiopathic toe-walking: does treatment alter the natural history? J Pediatr Orthop B. 2000 Jan;9(1):47-9.
4. Stricker SJ, Angulo JC. Idiopathic toe walking: a comparison of treatment methods. J Pediatr Orthop. 1998 May-Jun;18(3):289-93.

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