More than 60% of patients with toe walking who were referred from orthopedic surgeons
to a neurology clinic were found to have an underlying pathological diagnosis, a recent
While toe walking often is idiopathic, it can signal pathology such as cerebral palsy
(CP), peripheral neuropathy (PN), spinal dysraphism or autism spectrum disorder (ASD).
To determine the incidence of neurological etiology in patients with idiopathic toe
walking, researchers reviewed the records of 174 children referred from orthopedic
surgeons to a pediatric neurologist. Data were analyzed on sex, family and birth history,
age when patient started walking, bilateral vs. unilateral involvement, and upper
or lower motor neuron (UMN, LMN) signs on exam.
Results showed 108 children had a neurological etiology for toe walking. The most
common diagnoses were CP (37%), PN (17%), ASD (16%), hereditary spastic paraparesis
(HSP, 14%) and attention-deficit/hyperactivity disorder (8%).
Prematurity, delayed walking, unilateral toe walking, UMN and LMN signs, and hyperactivity
were more common in patients with an underlying pathology compared to those with no
known cause for toe walking.
For example, 91% of idiopathic toe walkers were younger than 18 months when they started
walking, while 43% of patients with CP were late in walking. In addition, a pathological
diagnosis was found more often when toe walking was unilateral compared to bilateral
(86% vs. 59%).
Furthermore, all patients diagnosed with HSP or spinal cord disorder and 90% of those
with CP had UMN signs on exam compared with 30% of those with idiopathic toe walking.
Ankle contractures, however, were not predictive of pathology.
“We find it reasonable to conclude that the following features in a patient with persistent
toe walking ought to trigger referral to a specialist: concerning birth history or
family history, delayed independent ambulation, unilateral involvement, upper or LMN
signs on examination, dysmorphic features, hyperactivity, or autistic features,” the