BACKGROUND: Children with idiopathic toe-walking, a common pediatric condition, 
walk some or all of the time on their toes. This condition often causes parental 
concern, with repeated medical contacts and a range of interventions including 
stretching, casts, injection of botulinum toxin A, and surgical procedures. The 
purpose of this cohort study was to document the natural history of this 
condition.
METHODS: In a population-based cohort of 1,401 healthy 5.5-year-old Swedish 
children, we found the prevalence of idiopathic toe-walking to be approximately 
5% (63 of 1,401). Of the 63 children who had ever been a toe-walker, 26 still 
were at the age of 5.5 years and were followed in the current study at 8 and 10 
years of age. At the 8-year follow-up, parents were asked by telephone whether 
their child had received any treatment or diagnosis since the 5.5-year 
assessment, as well as to what extent (approximately 25%, 50%, 75%, or 100% of 
the time) the child still walked on the toes. At the visit when the children 
were 10 years of age, their parents were asked the same questions. All 26 
children also underwent a neurological examination and an orthopaedic 
examination focusing on the lower extremities.
RESULTS: At 8 years of age, 6 of 26 children had ceased toe-walking, and by the 
age of 10 years, 50 (79%) of the original 63 patients had spontaneously ceased 
toe-walking. Idiopathic toe-walking did not result in contractures of the 
triceps surae. One subgroup of children displayed early contracture of the ankle 
and should thus not be considered idiopathic toe-walkers. Four of the children 
who still toe-walked at the age of 10 years demonstrated some neurodevelopmental 
comorbidity.
CONCLUSIONS: By the age of 10 years, 79% of the children who have ever been a 
toe-walker spontaneously develop a typical gait, without intervention or 
contractures of the ankle dorsiflexion. The diagnosis of short tendo Achilles 
should be retained as a separate diagnosis as there is a subset of children with 
this entity who should be treated early in childhood. Neurodevelopmental 
comorbidities are common among those who continue to toe-walk.
LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a 
complete description of levels of evidence.