Question
How does gait development in children with ITW differ from typical walking patterns?
Answer
In typical gait development, children begin independent ambulation between 9 and 15 months, with a mature heel-to-toe walking pattern emerging within a year of walking onset. By ages seven to eight, the neuromuscular system is mature, and children develop efficient postural control, sensory integration, and anticipatory movement adjustments. While some degree of forefoot contact is expected in early walkers due to immature postural control and short stride lengths, persistent toe walking beyond age two is atypical and may indicate ITW or another underlying condition.
Children with ITW exhibit several gait deviations, including a short stride length, limited hip extension in terminal stance, plantarflexion throughout the gait cycle, and an absent or reduced heel strike. Many lack all three ankle rockers, which are essential for efficient walking: the first rocker (eccentric tibialis anterior control), the second rocker (forward tibial translation over the foot), and the third rocker (gastroc-soleus propulsion). Additionally, they often compensate with excessive toe extensor activation instead of using the tibialis anterior for foot clearance. Over time, these deviations can lead to muscle imbalances, joint restrictions, and functional limitations such as difficulty squatting, jumping, or maintaining balance in single-leg stance.
This Ask the Expert is an edited excerpt from the course, "Idiopathic Toe Walking: Part 1," presented by Sally Le Cras, PT, DPT, PCS.
