Red Flags in the Evaluation of the Tiptoeing Child

Background: Tiptoeing is a common phenomenon in gate development. However, in some cases, it can be the first clinical sign of a medical condition, more often a neurological or muscle disorder. Aim: To provide a practical guide for paediatricians on how to approach tiptoeing and its possible causes. Methods: Input from the literature were used to construct this guide. We evaluated articles both on the general topic and the various conditions associated with tiptoeing. Results: Red flags in tiptoeing are its persistence for more than 6 months after the establishment of independent walking, its persistence after 2 years of age and its appearance afterwards. Historical and physical examination clues, together with few blood tests and radiological investigations, are key elements to direct the clinician's diagnosis in the right direction, especially nowadays, considering that many of these conditions have a specific treatment. Conclusion: In presence of red flags, tiptoeing should never be underestimated and must be considered a sign of a pathological condition until proven otherwise.