Tiptoe Through the Tulips: 3 things to consider if your child starts walking funny

When it comes to children’s developmental milestones, some memories are more vivid than others (my daughter scooted yet never crawled, and her first word -?????), but I think I’ll go out on a limb here and assert that MOST people recall pretty clearly when their kids took their first steps and started WALKING. Whether it’s captured on video or not, those first tentative steps are burned into the mind and are filled with excitement, representing a wondrous new beginning of improved exploration on the part of the child, and enhanced chasing and pursuit skills on the part of the parent.

I realized the other day when a #smartmomma wrote to me that I haven’t ever gotten into the topic of gait and walking, and there are some aspects that are really worthy of attention.

This particular parent had questions specifically about toe walking; however, concerns about gait and walking in general are fairly common in my urgent/emergent pediatric practice. So let’s put one foot in front of the other (could NOT help myself) and do a quick review.

Children most commonly come in for evaluation when they have a change in the WAY they walk. Whether it’s a limp, or an unwillingness to bear weight completely on one side, or toe walking. The first thing that enters my mind of course is some type of trauma: new walkers are more prone to falls and twists and bumps. Occasionally there’s a story behind the trauma, and in those situations solving the mystery is easy: a witnessed fall plus a limp and pain with examination of the ankle often means a simple X-ray provides the answer. Slam dunk. The X-ray findings are dealt with (fracture or not, sprain or not) and the healing process starts. Limp resolution is nearly universally achieved in this kind of scenario, and the end result is walking returns to normal.

But what if there ISN’T a history of some type of fall or trauma?

What if there’s a fever? What if the child has been or looks sick? This “strolls” into a totally different category of causes of abnormal gait. The trauma vignette above describes a problem with bones and/or ligaments, but we also need to consider what happens when the location of the problem is in the joint, between the bones. Infection and inflammation can get into that space and cause dramatic alterations in a child’s gait. Most simply, some children who have had a viral illness can get temporary inflammation in the lower extremity joints that we call “toxic synovitis.” This situation occurs when the body’s inflammatory system gets “turned on” from a recent viral infection, and then a few weeks later those inflammatory cells accumulate in a knee or hip and cause pain, decreased range of motion, and abnormal walking or limp. Kids who have this transient disorder actually look pretty well, and the diagnosis is usually made by an astute clinician without other tests. Toxic synovitis goes away all by itself with just some anti-inflammatory medicine (like ibuprofen),rest, and patience.

More seriously, bacteria can deposit into joints and cause similar symptoms, but worse. We call this scenario a “septic joint” and it is a true emergency. Children with this diagnosis look very ill, and often have a red, hot, swollen, painful joint, such as a knee. (This can occur in the upper extremity as well, as in “septic elbow”.) When the septic joint is the hip or knee, complete refusal to walk or bear any weight at all is typical. Bloodwork, ultrasound, and aspiration of the joint fluid for lab analysis are the components involved in making this diagnosis, and hospitalization with intravenous antibiotics and pain management are standard. Decreased range of motion in any joint is a symptom that should never be ignored, especially when coupled with systemic symptoms. Early diagnosis of a septic joint is critical, and can be life saving.

Ok, now for a less dramatic gait change.

Toe walking.

Lots of kids do this, and lots of parents are concerned that they do. There’s a part of me that is impressed that kids can actually sustain this the way that many do. Seems difficult to pull off. But does it mean that the child has cerebral palsy (CP), autism, or some other neurological problem? When should this sound an alarm bell?

As a general rule, children under the age of 2 who toe walk and are otherwise developing normally are not a worry.  In fact, almost half of all toddlers will toe walk at some point. Normal variant. The fact that a child at this age goes through a limited stage of toe walking is NOT predictive of any kind of neurological problem. Somewhere between the ages of 2 and 3, if toe walking is persistent and consistent, it starts to get my attention. Could there be an anatomical problem with the Achilles’ tendon at the back of the foot/ankle or is there a more rare neuromuscular issue emerging? If there is any associated developmental delay, then my suspicion increases. Close follow up with the child’s pediatrician and likely referral to a child neurologist are very important when sorting out whether toe walking has significance in this setting.

So, THREE THINGS that are at the front of my mind when a child comes in for a problem with WALKING:

1. Trauma
2. Infection/Inflammation
3. Normal variant

This short list isn’t 100% comprehensive but I do think it hits the highlights. I want to close with a reassuring thought: otherwise healthy kids who have changes/abnormalities/differences in their gait almost always get back to normal with appropriate evaluation and treatment, and much of the time all that’s needed afterwards is some reassurance, rest and maybe even a bit of gently leaving it alone. Those 5 months between the ages of 13 and 18 months when your daughter appeared to only walk on her tiptoes?—While not officially a developmental milestone, I’m guessing it will come up routinely at family holiday dinners until she’s well into adulthood. My daughter, Gemma-the-scooter, can attest to this.

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