Toe walking

Toe walking refers to a condition where a person walks on their toes without putting much weight on the heel or any other part of the foot. Toe walking in toddlers is common. These children usually adopt a normal walking pattern as they grow older. If a child continues to walk on their toes past the age of three, they should be evaluated by a doctor.
Toe walking can be caused by different factors. One type of toe walking is also called "habitual" or "idiopathic" toe walking, where the cause is unknown. It should only be diagnosed after all other conditions have been excluded. Other causes include a congenital short Achilles tendon, muscle spasticity (especially as associated with cerebral palsy) and paralytic muscle disease such as Duchenne muscular dystrophy. A congenital shortening of the Achilles tendon can be hereditary, can take place over time as the result of abnormal foot structure which shortens the tendon, or can shorten over time if its full length is not being used. Toe walking is sometimes caused by a bone block located at the ankle which prevents the antagonist movement, dorsiflexion. This cause is often associated with trauma or arthritis. It may also be one way of accommodating a separate condition, foot drop. Persistent toe walking in children has been identified as a potential early sign of autism.
It is estimated that 5% of healthy children are diagnosed with idiopathic toe walking. Idiopathic toe walking has also been found to be more prevalent in males than females when tested with very large numbers of children. This study looked for family history of toe walking and the connection to children demonstrating idiopathic toe walking (ITW).There 64.2% of children with ITW who were male and 348 children with a positive family history of toe walking. This means idiopathic toe walking may have a genetic link. In 30–42% of children with idiopathic toe walking, a family link has been observed.
Cause.
Unknown.
Idiopathic toe walking is always bilateral (or on both sides) and has no orthopedic or neurological cause. It is diagnosed after if it continues past the age of three. In this condition, children are able to voluntarily walk with the typical heel-toe pattern, but prefer to walk on their tip toes. In order for it to be considered idiopathic, the child's medical history should be clear of any neurological, orthopedic, or neuro-psychiatric conditions including other gait abnormalities. It is thought to be related to sensory processing challenges.
Two classifications of idiopathic toe walking have been established. The Alvarez's classification identifies the severity of the dysfunction based upon kinematics and ankle rockers. The Pomarino classification identifies the toe walking according to the individual's specific characteristics and characterizes them into three types based on the signs presented. 
Cerebral palsy.
Studies have been performed to determine the source of the association between toe walking and cerebral palsy. One study suggests that the toe walking—sometimes called an equinus gait—associated with cerebral palsy presents with an abnormally short medial and lateral gastrocnemius and soleus—the primary muscles involved in plantarflexion. A separate study found that the gait could be a compensatory movement due to weakened plantarflexion muscles. In people who have cerebral palsy and toe walk, there is greater plantarflexion force required for normal heel-to-toe walking than for toe walking. When typically developing children are tasked to perform different types of toe walking, their toe walking could not reduce the force to the levels that children who toe walking with cerebral palsy have when they walk. This suggests that toe walking associated with cerebral palsy may be due to abnormally weakened plantarflexion that can only manage toe walking.
Diagnosis.
A doctor will typically evaluate if the toe walking affects both or one leg, what the child's range of motion is (how far they can flex their feet) and perform a basic neurological exam. Treatment will depend on the cause of the condition.
Treatment.
For idiopathic toe walking in young children, doctors may prefer to watch and wait: the child may "outgrow" the condition. There are limited treatments that demonstrate long term walking change. But there are treatments that can change the length of muscles in the short term.
For toe walking which results from more serious neuro-muscular conditions, additional specialists may need to be consulted.