Initial pre-referral workup

Clinical history

Usually idiopathic; family history of toe walking.

Although rare, rule out significant conditions such as spinal dysraphism, muscular dystrophy and cerebral palsy.

Physical examination

• gait assessment
• inspect spine
• functional tests – check if able to stand with heels down with trunk straight and able to walk on heels
• calf length
• calf size
• neurological assessment

Investigations

If suspicious:

• spinal X-ray
• CPK

GP management

Consider referral to paediatric physiotherapist for assessment and management.

Refer parents to Toe walking in children (fact sheet) and guide to calf stretching.

Indications for specialist referral

Routine

• inability to dorsiflex foot beyond neutral, stand with heels down or walk on heels
• signs of cerebral palsy with hypertonia, hyperreflexia or ataxia
• calf hypertrophy
• asymmetry
• abnormal spine examination