ITW consensus statement
 
Definition:
1.     ITW is defined as bilateral toe walking that started from initiation of walking and is not associated with any known neurological condition, and persistent beyond the age of two.
2.     Neurodiversity (ASD/ADHD) can co-exist with ITW and is not an exclusion to the diagnosis
Initial Assessment
3.     Every referral of ITW should first be seen by an experienced practitioner that can assess, identify, diagnose and refer to a developmental paediatrician/ paediatric neurologist when appropriate.
4.     Assessment should involve family history, developmental history, basic musculoskeletal and neurological examinations including range, strength and gait.
5.     In the case of any abnormal / positive findings in the neurological examination, a referral should be made to the appropriate specialist for consideration of further diagnostic tests and imaging.
 
Treatment Decision
6.     Passive ankle dorsiflexion in patients with ITW should be measured in knee flexion and extension in a consistent manner with the heel in a neutral position.
7.     Ankle contracture relevant to ITW gait is defined as a patient who is unable to dorsiflex to plantigrade
8.     The aim of primary treatment is not solely to address toe walking but to manage the symptoms affecting the child who toe walks.
9.     Lower limb pain can be an indication for treating ITW
10.  Psychosocial impact can be an indication for treatment of ITW
11.  Asymptomatic ITW without ankle joint contracture does not require treatment
 
Primary Treatment
12.  Primary treatment can be provided by any trained and experienced health practitioner
13.  Non-surgical treatment should always be the first choice of treatment
14.  Stretching programmes can be provided even if dorsiflexion range allows heel contact in weightbearing
15.  Primary treatment includes education and advice, stretching, strengthening, casting, and day and night splints as decided by the treating health practitioner based on the clinical examination
16.  Serial casting can be attempted to reduce equinus contractures
17.  Heel contact should be achieved in weightbearing casts with a heel raise to accommodate plantarflexion
18.  Night splints could be provided to maintain range of motion
19.  The aim of primary treatment is to address the indication/ symptom and hence the outcome of the treatment would be whether that goal was achieved
20.  Failure of primary treatment is defined as the inability to achieve the shared goal for intervention during an agreed time frame e.g. failure to reach plantigrade stance with six weeks of casting
21.  There is no need for follow up after successful primary treatment and patients could be re-referred if needed
22.  Following discharge from primary treatment, patients and families should be advised regarding potential risk factors for recurrence of ITW and how to seek re-referral into services if needed
23.  Recurrence of ITW is defined as ITW that was previously treated successfully and now lost that improvement in symptoms (range, pain etc.)
24.  In the case of recurrence following a successful intervention, there is room for another attempt in primary treatment
25.  Patients with ITW that have neurodiversity should be offered treatment with appropriate counselling regarding recurrence rates
 
Surgical Treatment
26.  Referral for consideration for surgery is indicated when primary treatment was not successful or was inappropriate
27.  Carers should be involved in the treatment decision making
28.  Decision of surgery type (Hoke/ Open/ Gastrocnemius) should be made by the operating surgeon based on the clinical findings
29.  If other structures needs addressing in surgery (e.g. plantar fascia or flexors) they can be added to the procedure
30.  There is a need for a follow up after surgical intervention for at least 12 months
31.  Outcomes should be measured and documented after any intervention

Consensus Group Members:
Jennifer Harris
Anne McNee
Christine Douglas
Sarah Dewhurst
Amanda Trees
Mia Dunkley
Laura Deriu
Alpesh Kothari
John Cashman
Derfel Williams
Jonathan Wright