A typical presentation of idiopathic toe walking (ITW) is that of a child who can heel-toe walk on request but habitually walks on his or her forefoot. ITW was first noted in a case review in 1967 [1
] and was diagnosed as a congenitally short tendo-achilles. This condition is no longer found in the literature; instead reference is made to a clinical condition called habitual, or more recently, idiopathic toe walking (ITW) [2
]. ITW is a diagnosis that can only be made in the absence of any medical condition known to cause toe walking [2
]. Table [5
] shows a range of medical conditions associated with toe walking.
Known conditions associated with or causing toe walking
The incidence of ITW has been reported as present in up to 7% of the general paediatric population in one small study [25
]. As this study had small participant numbers and large variances in cultural influences, it is suggested that the findings are not a true indication of the prevalence of ITW. The incidence of family members reporting an ITW history, according to a number of retrospective studies [2
], is between 10-88% with the only prospective study reporting an incidence of 34.1% (95% CI) [3
]. It is also noted that having family members who have displayed ITW did not conclusively lead to further generations presenting with this gait type. ITW presents in either gender [3
], with no gender displaying predominance. A link between speech delay, with or without a gross motor skill delay, and ITW has been identified in a number of studies [2
]. There is an absence of research into the habitual nature of ITW or the social or familial influences of this gait style and no literature on any influential factors contributing to the initial development of this gait pattern.
The majority of literature on ITW focuses on its relationship to equinus. The suggestion that equinus is secondary to the development of this gait abnormality is common, but as yet unproven [2
]. The presence of ITW post orthopaedic treatment and beyond has now been highlighted both in case controlled studies [3
] and within a case report [35
] leading to conflicting opinions on the necessity and effectiveness of treatment. The long-term effect that ITW has on the foot and ankle has not been definitively established, although it has been noted that there is some evidence of excessive external tibial rotation present in long-term toe walkers [36
] and a positive association with equinus [2
]. There continues to be debate within the literature of the need for treatment based on these associations.
Studies on the treatment of ITW include: comparative outcome analysis of surgical achilles tendon lengthening compared to or in combination with serial casting [36
]; anecdotal case reviews [1
]; and retrospective studies [28
] on many different conservative treatment regimes which primarily involve stretching and some form of orthotic therapy or footwear. Two long-term retrospective studies report ITW persisting in children regardless of treatment received [28
A number of authors within published texts suggest that ITW has a positive relationship with sensory processing dysfunction [14
], yet there is limited research establishing this relationship. The content of these texts are currently utilised as teaching material within tertiary educational settings, all have been published or subsequent editions published within the last twelve years. Sensory processing is a conceptual model that is utilised in occupational therapy practice [43
]. It has been defined as "the neurological process that organises sensation from one's own body and from the environment and makes it possible to use the body effectively within the environment" [44
]. While sensory processing is a complex theory, it can be explained in terms of the primary and secondary senses of the body. There are five primary senses that the body relies on for its engagement within the environment. Vision or sight, hearing, touch, smell and taste are primarily the sensors that provide feedback from the environment. Secondary senses, vestibular and proprioception, provide feedback on where the body is in space, its location in response to other joints and its direction of movement [43
]. According to sensory processing theory, the integration of the vestibular, proprioception and tactile systems are the building blocks on which normal body movement relies. These building blocks then form the base that allows children to develop their motor skills and cognition. These sensory systems, by the integration of the sensory input from the environment, then guide and organise motor control of the body. The sensory feedback that is obtained during and after an activity allows the result to be challenged within the brain and modified to gain the required result [42
]. Sensory processing dysfunction (SPD) is a diagnosis given when these processes are not working appropriately.
The purpose of this paper is to examine the literature and provide a summary of what is known about the relationship between toe walking and SPD.