Idiopathic Toe Walking: A common Mis-diagnosis
which is actually secondary to flexible flatfoot
By Dr Louis DeCaro
This is the case of a 2 year old child. She is a late walker (20 months). The patient has been walking for 4 months, mostly still only cruising, with off and on Toe walking.
The child is struggling in early intervention with hip and core strength. She was sent to me to evaluate significant ankle collapse and toe walking. The patient was dispensed littleSTEPS and will do phenomenal.
This patient illustrates many pediatric ideas :
1. The ankle collapse is NOT from the ankle (seen in comparison to picture #1 barefoot and picture #3 in littleSTEPS). It is from the foot!
2. A major cause of toe walking is a flexible flatfoot (explained below)
3. Early intervention will struggle with GM goals until the foundation is secured! It is now – she will be off to the races!
This is a classic case of the patient having SUCH a flexible flatfoot that she must toe walk to compensate. That is basically the only way the child can balance and walk (by going up on her toes). Traditionally this is diagnosed as idiopathic toe walking. The child does not have a rigid flatfoot, it is flexible, or as I refer to it a “False flexible flatfoot” – meaning that the significant flexibility of the foot at this age causes increased pronation and the ankle collapses which occludes the arch. When the patient stands on their tippy toes the calcaneus inverts and an arch “pops out”. Mom is given a handout of an article I published on this. Due to the extreme nature of the flexible foot the ankle collapses, the hip muscles are not able to properly develop, and walking is delayed. The foundation of the child is inhibiting her from gross motor goals. She only needs to be supported at the foot, because that is where the issue is coming from. Supporting above the ankle inhibits movement and is unnecessary. With littleSTEPS orthotics she is seen standing in resting calcaneal stance position with a much better posture and decreased base of gait (more parallel stance). This will significantly allow the core and hip muscles to fire more normally and get stronger faster. The child may or may not need OTS following this core strengthening and flexible foot phase however it is too early to tell.
