Toe walking after three: how serious could it be?

BMJ Case Rep, 2018 · DOI: 10.1136/bcr-2017-223589 · Published: May 20, 2018

Neurology Pediatrics Research Methodology & Design

Simple Explanation

This case report describes a 4-year-old girl who presented with toe walking, leg pain, unsteady gait, and frequent falls. Initial evaluations were normal, but further investigation revealed a rare spinal tumor. The girl's toe walking, initially dismissed, turned out to be an early sign of a growing schwannoma (a type of nerve tumor) in her cervical spine. This highlights the importance of considering neurological causes for persistent toe walking in children. Following surgical removal of the tumor and physiotherapy, the patient made an excellent recovery, emphasizing the importance of thorough evaluation and timely intervention in cases of toe walking accompanied by other neurological symptoms.

Study Duration

2 months

Participants

A 4-year-old girl

Evidence Level

Level 4; Case Report

Key Findings

1
Toe walking, when accompanied by leg pain, unsteady gait, and frequent falls, can be indicative of serious underlying neurological conditions such as spinal tumors.
2
Upper motor neuron signs, such as hyperreflexia and spasticity, in conjunction with toe walking, warrant a thorough evaluation for supraspinal and spinal etiologies.
3
MRI of the cervical and thoracic spine revealed a large intradural and extradural mass arising from the right C7 nerve root, leading to the diagnosis of a benign schwannoma.

Research Summary

A 4-year-old girl with no significant medical or family history presented with toe walking, leg pain, unsteady gait and frequent falls for 2 months. MRI cervical and thoracic spine showed a large intradural and extradural mass arising from the right C7 nerve root, widening of the neural canal with evidence of cord compression. Pathology revealed spindle cell tumour with extensive expression of S100 protein and CD56, with Ki-67 proliferation index of 1%–2% consistent with benign schwannoma.

Practical Implications

Clinical Vigilance

Clinicians should consider neurological causes in children presenting with persistent toe walking, especially when accompanied by other neurological signs or symptoms.

Early Diagnosis

Prompt evaluation, including spinal imaging, is crucial in cases of toe walking with red flag signs to allow for timely intervention and improved outcomes.

Differential Diagnosis

Toe walking can be a manifestation of various conditions, ranging from benign musculoskeletal issues to complex central nervous system pathologies, requiring a thorough differential diagnosis.

Study Limitations

1
Single case report limits generalizability.
2
The rarity of schwannomas in young children makes it difficult to draw broad conclusions.
3
Lack of long-term follow-up data beyond 6 months.

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