The strange case of the tiptoeing toddler

The phone call covered a wide range of childcare questions, from feeding techniques to sleep challenges, but the issue that bothered the mother most was the fact that she had a tiptoeing toddler. Her child had been walking for a few months and was getting to be a seasoned upright traveler. The little guy was, however, spending part of each day walking up on his toes.

I'd examined the toddler during all of his well-baby exams and he always appeared neurologically intact and well on his way to meeting all of the typical developmental milestones. The boy's feet were also appropriately flexible, and he was able to walk "flat-footed" when he wanted to. Therefore, I felt comfortable reassuring the mother that her son was simply going through a normal toddler phase. We went on to discuss various ways to discourage this style of walking in order to avoid the later development of tight heel cords.

Experts at the American Academy of Orthopaedic Surgeons explain that much of the intermittent toe walking seen before 18 months of age is actually not of concern, as it is considered a normal variation of early gait development in otherwise healthy toddlers.

Once the toe walker moves out of this toddler stage, and after neurologic, neuromuscular and neurodevelopmental disorders such as cerebral palsy, muscular dystrophy and autism have been considered and ruled out, the condition can be referred to as idiopathic or habitual toe walking.

If toe walking persists, or in cases where the condition is caused by or leads to a tight or shortened Achilles tendon, or heel cord, referral to an orthopedic surgeon is indicated. Possible treatment options include close observation, physical therapy, bracing with an ankle foot orthosis, serial casting, use of Botox injections and, in more severe cases, surgical repair.

In a comprehensive review of the topic, University of Miami orthopedic specialist Dr. Stephen J. Stricker notes that about 2 percent of patients in his pediatric orthopedic practice toe walk. About 40 percent - with some studies reporting as high as 70 percent - of habitual toe walkers have a positive family history of the condition, with a sibling or parent also displaying the current or past use of a similar tiptoe gait.

Dr. Stricker predicts that in most cases, idiopathic toe walking will resolve without incident, pointing out that, with the exception of high-heel wearers, few adults continue their youthful toe-walking ways.

• Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.