Idiopathic Toe Walking: Silfverskiold Test, Serial Casting and Gait Retraining
In short
Idiopathic toe walking is a diagnosis of exclusion. Learn how to perform the Silfverskiold test, apply serial casting protocols, and re-educate heel-toe gait.
In this guide (4 sections)
Understanding Idiopathic Toe Walking (ITW)
Idiopathic Toe Walking (ITW) refers to bilateral toe-walking in children over 2 years of age without any underlying neurological, orthopaedic, or psychiatric disorder.
While intermittent toe-walking is common during the early toddler stage of gait development (up to 2 to 3 years), persistent toe-walking leads to adaptive shortening of the Achilles tendon, calf muscle hypertrophy, and secondary flatfoot deformity due to midfoot breakdown.
Differential Diagnosis and the Silfverskiold Test
ITW is strictly a diagnosis of exclusion. Clinicians must rule out mild spastic diplegia, tethered cord syndrome, muscular dystrophy, and autism spectrum disorder before confirming idiopathic etiology.
| Clinical Parameter | Idiopathic Toe Walking (ITW) | Spastic Diplegia (Cerebral Palsy) | Sensory-Seeking Toe Walking | |
|---|---|---|---|---|
| Neurological Signs | Normal deep tendon reflexes; no clonus; negative Babinski. | Hyperreflexia; sustained ankle clonus; positive Babinski. | Normal reflexes; sensory modulation differences. | |
| Gait Characteristics | Symmetrical bilateral toe-walking; can stand flat when prompted. | Asymmetrical or stiff gait; scissoring; crouch tendencies. | Toes on certain surfaces; walks flat barefoot on grass. | |
| Silfverskiold Test Result | Dorsiflexion restricted with knee straight, normal with knee bent. | Spasticity increases with velocity (Modified Ashworth). | Full passive ankle dorsiflexion (>15 degrees). |
Serial Casting and Physiotherapy Protocol
When passive ankle dorsiflexion is restricted below neutral (0 degrees), conservative therapy with serial casting provides the highest success rate without surgical intervention.
- Serial Casting Protocol: Apply bilateral below-knee fiberglass walking casts with the ankle positioned at maximum comfortable passive dorsiflexion with subtalar joint in neutral. Change casts weekly for 4 to 6 weeks, gaining 5 degrees of dorsiflexion per cast.
- Post-Casting Orthotics: Immediately following cast removal, fit the child with daytime rigid or articulating Ankle-Foot Orthoses (AFOs) for 3 to 6 months to prevent calf muscle re-tightening.
- Active Gait Retraining: Practice heel-strike gait drills using auditory feedback cues (squeaker shoes), walking uphill on ramps, walking backward on inclines, and deep squat play.
Frequently Asked Questions
How is the Silfverskiold test performed?
With the subtalar joint held in neutral, passive ankle dorsiflexion is measured with the knee fully extended and then with the knee flexed to 90 degrees. If dorsiflexion is restricted in extension but normal in flexion, isolated gastrocnemius tightness is confirmed.
When is surgical Achilles lengthening considered?
Surgical lengthening (such as gastrocnemius recession / Strayer procedure) is reserved for children older than 5 to 6 years with severe fixed equinus contractures (>10 degrees plantarflexion) that fail to respond to serial casting.
Why do children with autism frequently toe walk?
Toe walking in autism spectrum disorder is frequently linked to sensory processing differences, either seeking high proprioceptive joint compression or avoiding tactile input from heel contact on cold or textured floors.
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