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Toe-walking in Children Care Pathway Overview

Toe walking in children is a normal part of a child's development and usually does not require referral into Orthopaedics. Please manage in Primary Care with advice, encouragement and self-management.

Practice Point

The advice in this pathway applies to patients up to musculoskeletal maturity at approximately 18 years of age

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Red Flags
  • Persistent pain, redness, heat, swelling, raised body temperature
  • History of trauma/injury/fracture
  • Inability to weight bear
  • Sudden onset unilateral toe walking
  • Multiple joint pain/swelling
If fracture suspected, follow the Fracture pathway
If infection suspected, treat accordingly
If multiple joint pain/swelling consider Rheumatology referral
For persistent foot or ankle pain, weakness, limping swelling or stiffness, encourage patient to self-refer into Physiotherapy Services (GCS)
Presentation

Toddlers may walk on their toes as part of their normal development. This usually resolves as children get older. A small percentage will continue to toe walk.

The facts:

  • It often affects both feet.
  • The cause is often unknown and this is called idiopathic.
  • It may occur in several members of the family.
  • It does not usually cause pain.
  • Children can perform age appropriate activities.
Differential Diagnosis
  • Sensory processing disorders (Asperger's, Autistic spectrum disorder etc.)
  • Congenital contracture of the Achilles tendon
  • Tarsal coalition
  • Bone cyst/tumour
  • Neurological disorders causing tight Achilles tendon – e.g. cerebral palsy, muscular dystrophy
  • Fracture (follow the Fracture pathway)
  • Infection (treat accordingly)
  • Developmental hip dysplasia
  • Perthes disease
  • Slipped upper femoral epiphysis (SUFE)
  • Inflammatory arthropathy
Initial Primary Care Assessment

Examination may include:

  • questioning about birth history
  • examination of spine and lower extremities for cutaneous abnormalities, leg-length discrepancy, asymmetric or abnormal muscle development, pelvic asymmetry and fixed-foot deformities
  • observation and assessment of gait
  • assessment of range of motion of the knee, hip and ankle joints
Primary Care Management

Toe-walking in children is a normal part of a child's development and usually does not require referral into Orthopaedics. Please manage in Primary Care with advice, encouragement and self-management.

Provide advice/encouragement:

  • Encourage activities with flat feet on the floor e.g. squatting to play with heels on the floor, walking on heels or marching games
  • Provide Parent/Carers/Patient with the ‘Toe Walking’ Patient Information leaflet which includes exercises:
    • In some cases stretching of the Achilles tendon may be required. This can be done up to 5 times a day. It may take several months to notice the benefits of these.
  • Correct footwear is important for any child to ensure support during periods of growth and development – provide Parent/Carers/Patient with the 'First shoes' Patient Information Leaflet if appropriate

Practice Point

The advice in this pathway applies to patients up to musculoskeletal maturity at approximately 18 years of age

When to Refer

If additional support is required to manage the problem, Gloucestershire Care Services (GCS) provides foot and ankle services in Gloucestershire.

The main entry point for foot and ankle services is via Core services, accessed via the online self-referral form, (click here for printable link), which the patient can complete themselves if able to and willing.

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