The condition in which children walk on their toes is called “hippopody walking” or “tip toe walking”. In the case where there is no obvious pathological cause, we say that the child has “idiopathic tip toe walking”.

Children at the beginning of independent walking often walk with the toes and not with the whole foot. Around the age of 2 they begin to develop adult-like gait patterns, however, it is clear that mature gait is established by the age of 3. This means that the initial phase of walking, which is the contact of the heel with the ground, also known as “heel strike”, must appear in a normal child at the age of 3 years.

If this does not happen, it is imperative to rule out diseases that can cause such a situation in the first instance. Such diseases are congenital (congenital clubfoot in a mild form), neuromuscular (cerebral palsy, poliomyelitis and others), local anatomical problems (post-traumatic shrinking of the gastrocnemius), muscular dystrophy and rarely psychological causes.

Thus, when a child continues to walk on the nose after the age of 3, mild cerebral palsy in the form of mild diplegia, muscular dystrophy, spinal cord immobilization syndrome, spinal cord tumor, dysraphism must first be ruled out. of the spinal cord, interstitial myopathy and acute myopathy. Also, the perinatal history (age of birth – Apgar score), the delayed appearance of neuromuscular skills and the family history must be taken into account and therefore, the examination by a pediatric neurologist in the first year and if the pediatrician judges it, is of major importance from a diagnostic point of view. And if the neurologist deems it necessary, the diagnostic paraclinical tests that help in the differential diagnosis are the dynamic electromyogram, gait analysis and even the electroencephalogram.

However, in the event that such problems are ruled out after a very good check-up, then we consider that the child presents the so-called idiopathic tip toe walking (TTW) which is a separate clinical entity and is related to local anatomical variations.

The main cause of idiopathic TTwalking is “short Achilles tendon” due to shortening of the gastrocnemius or subtibialis muscle.

The main problem of these children is that they cannot do dorsal extension of the ankle because of the “short Achilles tendon”.

In order for someone to have a normal gait, the dorsiflexion of the ankle should be at least 18 degrees, which these
children have not.

Therefore, the therapeutic approach aims to somehow improve the upward movement of the foot (ankle dorsiflexion). There are various treatment options that improve this condition such as:

• Stretching exercises of the gastrocnemius – subtibial muscles.
• Application of corrective plasters for 8-10 weeks.
• Night guards after application of casts to maintain correction.
• Cnipodal guardians.
• Botox injection.
• Surgical intervention.

The choice of treatment depends on the age and severity of TTwalking. In younger children, the combination of physical therapy and the application of a shin splint seems to be the best combination. Whereas in older children, surgical intervention, if functional problems exist or are estimated to exist in the future, seems to be the best solution.

in conclusion

When a child walks on the nose after the age of 3, a possible neurological disease must first be ruled out. If the child is indeed diagnosed as an idiopathic TTwalker, treatment if necessary is decided based on the severity of the clubfoot and the presence or potential future appearance of functional problems.