Toe-walking is not an uncommon habit in two and three year olds. Frequently children that toe walk can be coaxed into normal gait patterns with encouragement. This habit becomes less common as the child grows. A child usually has a normal heel strike by age four.
The etiology of persistent toe-walking is unknown but may be associated with neurological conditions or short heel cords. Therefore, a thorough physical examination, including gait analysis and neurological examination, is necessary. If contracture of the heel cord exists, the chance for spontaneous improvement without treatment decreases.
Mild variants of toe-walking may improve or may cause no functional limitations if left untreated. Treatment options for persistent toe-walking include serially casting to stretch the tight heel cords, orthotics (inserts in shoes) and surgical intervention.
Serial casting is initiated by placing a short-leg walking cast (cast from below knee to tips of toes) and this cast may need to be changed every 1-2 weeks to further stretch out the heel cord. Sometimes initial success will be tempered by recurrence. This return of toe-walking sometimes will require additional treatment. After the foot is level, this is usually maintained with an ankle-foot orthosis (brace), temporarily. In a severe case, surgical heel cord lengthening may be necessary.