Selective percutaneous myofasciotomy in persistent toe-walking: Anatomical rationale and surgical technique

Persistent toe-walking is a gait abnormality characterized by forefoot initial contact and reduced or absent heel strike beyond early childhood. Although often regarded as a transient developmental variant, persistence of this pattern may lead to progressive limitation of ankle dorsiflexion, fixed equinus contracture, and long-term functional impairment. Toe-walking may occur as an isolated idiopathic condition or in association with neurological, neuromuscular, or genetic disorders. Increasing evidence suggests that a subset of patients previously classified as idiopathic harbor underlying hereditary or neuromuscular abnormalities. When left untreated, persistent toe-walking may result in inefficient gait mechanics, increased energy expenditure, compensatory proximal joint adaptations, musculoskeletal pain, and limitations in physical activity. Conservative management including pyramidal insoles, physiotherapy, stretching, orthoses, serial casting, and botulinum toxin injections may be effective in early or functional stages; however, these approaches frequently fail once fixed myofascial contractures develop. Traditional surgical lengthening procedures can restore ankle dorsiflexion but are associated with risks such as over-lengthening, postoperative weakness, recurrence, and soft-tissue morbidity. Selective percutaneous myofasciotomy represents a minimally invasive alternative based on targeted subcutaneous release of fibrotic myofascial structures while preserving surrounding healthy tissue and normal neuromuscular anatomy. This article describes the anatomical rationale, indications, and surgical technique of selective percutaneous myofasciotomy for the treatment of ankle equinus in patients with persistent toe-walking. By addressing localized myofascial restrictions with minimal surgical trauma, this technique aims to restore ankle mobility, facilitate gait normalization, and enhance postoperative rehabilitation, while minimizing recurrence and preserving muscle function and improving long-term outcomes in affected children and adolescents. Level of evidence: Level V.