We are in the waiting room of an orthopedic surgeon who is going to look at our son for a walking problem. They are an hour behind schedule so I thought I’d cruise the Web and look for information. The basic problem is that he is four years old and still walking up on his toes. He can walk flat footed if we ask him to but most of the time, he’s always up tip-toeing around. What can they do about this kind of problem?

Occasionally, a child will learn to walk up on toes rather than the more typical heel-toe pattern we are used to seeing. It’s not really something to be concerned about unless it continues as the child gets older. Children like your son who are still toe walking after age two should be evaluated more closely by their pediatrician or perhaps even referred to a specialist such as an orthopedic surgeon.

There are many possible causes for this type of persistent gait (walking) pattern. The list includes muscular, neurologic, neuromuscular, and anatomic causes. Sometimes it’s something as simple as a slight leg length difference (one leg shorter than the other). It can be a sign of a general (“global”) developmental delay.

Most of the time, the condition is referred to as idiopathic, in other words: cause unknown. The diagnosis may take some time as the physician examines the child, considers the history, and conducts some specific tests. The calf muscle will be tested for tightness called a contracture. A neurologic exam will be performed.

More advanced testing such as EMGs (electromyography) of the muscles and computerized gait analysis may help identify unusual patterns of muscle activation. In the case of true idiopathic toe walking where there is no neuromuscular or neurologic problem, treatment depends on the age of the child. For example, children who have not reached their second birthday may just be observed carefully. It is possible that over time, the child will start to walk more normally.

After age two, the condition of the muscles is checked. If there is no contracture (muscle tightness with loss of lengthening), the child may be helped by stretching exercises. Casting the leg or wearing a special brace may help as well. When the muscle is contracted and the ankle cannot move past neutral, then surgery to lengthen the muscle may be advised. Surgery may also be required when conservative care with stretching and bracing or casting hasn’t worked.

Although toe walking in young children can be a sign of a true developmental problem, most of the time, it is not. That’s when it’s referred to as idiopathic toe walking. Idiopathic toe walking is just one of those things adults can’t explain and kids outgrow. In cases where it persists past age two, efforts should be made to lengthen the calf muscle. This can be attempted first with a conservative approach with surgery as the backup plan. Children with an underlying neuromuscular or neurologic cause for their toe walking may be treated differently.