Toe Walking

How Kids in Motion can Help!

Understanding your child’s development and behaviors can be challenging and overwhelming. With many different opinions and suggestions on what your child should or shouldn’t be doing can be stressful and confusing. Although, having the proper resources and education is important to improve your knowledge on ways to help your child develop to the best of their ability and Kids in Motion is here to help.

Objectives to understand regarding Toe Walking:

Understand age appropriate walking patterns
Recognize signs and symptoms of toe walking
Identify causes of toe walking
Understand associated complications of toe walking
Learn appropriate treatment interventions for children that walk on their toes

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What is Toe Walking?

Kids in Motion

Toe walking occurs when a child walks up on his or her toes or the ball of the foot so that the heel does not contact the floor. This condition is common in new walkers but is considered abnormal for children over the age of 2-3 years. Most often, a child will outgrow the condition on their own and begin to utilize a mature heel-to-toe walking pattern. However, if the toe walking persists past this age, seeking medical attention is recommended (American Academy of Orthopaedic Surgeons, 2017; Mayo Clinic, 2018).

What causes a child to walk on their toes?

A child can walk on their toes for a variety of reasons. Most commonly, toe walking is considered “idiopathic”, meaning the exact cause is unknown. This cause is often determined by ruling out all other possible causes of toe walking. Idiopathic toe walking may be common among family members. Other causes may include (American Academy of Orthopaedic Surgeons, 2017; Cueny & Deb, 2019; Mayo Clinic, 2018):

Tight calf muscles: a normal heel-to-toe walking pattern requires 10-20 degrees of ankle dorsiflexion (toes up). May affect one or both legs.
Leg length discrepancy: one leg is longer than the other, resulting in compensations seen when walking. Toe walking may often occur on only one leg.
Underlying medical diagnosis such as Autism, Cerebral Palsy, or Muscular Dystrophy
Sensory: a child can walk with heels down when asked. Therefore, toe walking is more of a preference. The child may present with tactile defensiveness, walking on their toes so that less of their foot is in contact with the floor. Additionally, a child may be seeking additional proprioceptive input through the joints of their feet. By walking up on their toes, their bodyweight is centralized to one location, therefore providing extra input.

What are signs/symptoms of toe walking?

Many children who walk up on their toes may demonstrate any or all of the following (American Academy of Orthopaedic Surgeons, 2017; John Hopkins Medicine, 2019):

Tightness within the calf muscles and/or a short Achilles tendon
Foot or leg pain
Developmental delays, especially with balance skills and those related to jumping
Problems wearing shoes such as high tops
Increased difficulty participating in activities such as roller skating or ice skating
Decreased endurance with walking or running

What are associated complications with toe walking?

It is imperative that a child receives early treatment for toe walking and if applicable, not ignored as a familial trait. By continuing to walk up on their toes, a child puts themselves at risk for development of the following complications (Cueny & Deb, 2019):

Placement of abnormal stress along the bones and ligaments of the lower extremities, which can result in development of bony abnormalities and pain.
Tightening of the calf and hamstring muscles and increased definition of these muscles from being overworked. As a result, other muscles of the body such as the glutes, quadriceps, and peroneals become weak and atrophy (become smaller).
Impaired static and dynamic balance skills, putting a child at risk for falls.

What can I do to help treat my child’s toe walking?

Your child’s pediatrician is likely to refer your child to physical therapy and Occupational therapy if a sensory issue, to assist with addressing your child’s toe walking in a conservative manner. A physical therapist can assist with developing a strengthening and stretching program for your child’s tight calf muscles to facilitate obtainment of the necessary ankle dorsiflexion (toes up) range of motion needed to utilize a heel-to-toe walking pattern. They will provide necessary gait training and assist with developing strategies to be utilized at home to correct your child’s walking pattern. A physical therapist is also able to address any developmental delays that are associated with your child’s toe walking. If the child’s toe walking is sensory based, the physical therapist may also implement and provide strategies to address their sensory needs in order to promote walking with the heel in contact with the floor.

In more severe cases, a physical therapist may assist with a process called serial casting. In this process, a short leg cast is applied at one-week intervals to progressively stretch tight muscles while improving the foot and ankle position. While in these casts, a child can walk and participate in low-impact activities while wearing a cast boot. Conversely, the physical therapist may recommend use of night splints to assist with stretching the child’s muscles during the nighttime hours. A night splint is an adjustable, custom orthotic brace that places the calf muscles in a stretched position for a prolonged period while the child sleeps.

If a child has the functional ankle range of motion to walk using a heel-to-toe pattern, but continues to prefer to walk on their toes, the physical therapist may recommend use of an orthotic such as an ankle-foot-orthosis (AFO) or a toe walking supramalleolar orthosis (SMO) to facilitate heel contact when walking. An AFO may also be utilized to improve a child’s ankle range of motion while providing a stretch to the calf muscles, like a night splint, during the daytime hours.

If conservative treatment is not successful, your child’s pediatrician may recommend Botox injections and/or surgical intervention in order to allow them to achieve a foot flat position when walking. Botox is injected into the tight musculature to assist with improving the range of motion within this muscle. The effects of Botox can be seen for up to 3-6 months following the injection and are often completed in conjunction with serial casting. Surgical interventions will assist with lengthening the short Achilles tendon or calf muscle to allow for improved range of motion and function within the foot and ankle. (American Academy of Orthopaedic Surgeons, 2017; Cueny & Deb, 2019; John Hopkins Medicine, 2019; Mayo Clinic, 2018)

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Kids in Motion Pediatric Therapy clinic provides services in all areas from speech, occupational, and physical therapy to address the signs/symptoms stated above related to toe walking.

Speech therapy will help improve your child’s communication skills by learning verbal and/or nonverbal skills. A speech therapist will engage your child in a variety of auditory and verbal stimuli such as story books, picture cards, interactive games, actual objects, etc. using different approaches and techniques to improve language skills. A speech therapist can also teach the use of an augmentative communication devices, Picture Exchange Communication System (PECS), and American Sign Language. These devices and techniques can improve communication by using pictures and symbols to ask and answer questions when interacting with others.

Occupational therapy will use creative therapeutic activities to increase independence and success in ADL, fine motor, visual motor, and sensory processing skills. Occupational therapist will introduce innovative methods to improve self-dressing, self-hygiene and self-feeding skills. Your child will engage in client centered activities to increase strength and coordination/control in hands and upper extremities to complete age appropriate fine motor and visual motor skills with greater success. Occupational therapist will demonstrate and educate family on variety of sensory diet strategies specific for your child’s needs to improve regulation to perform optimally in everyday activities.

Physical therapy will help improve your child’s strength, coordination, and balance through therapeutic exercise and activities to increase success in age appropriate gross motor skills. Child will also engage in tasks such as obstacle courses incorporating variety of gym equipment to improve motor planning skills. Physical therapist may target gait retraining if toe-walking is present by working on your child’s range of motion, strengthening and incorporating different sensory techniques. Consultation with an orthotist can also be provided if needed.

Still have questions and concerns?

We are committed to helping children of all abilities achieve and live their full potential. With experienced and compassionate Physical, Occupational and Speech Therapists and four locations to serve you, we feel confident that you will be more than satisfied with the care and support your child receives.

Check out our free Interactive Online Screener – once completed, it will respond with ideas to help your child in the areas you specify they might be having trouble with or contact us at 248-684-9610.

References:

American Academy of Orthopaedic Surgeons. (May 2017). Toe walking. Retrieved from https://orthoinfo.aaos.org/en/diseases–conditions/toe-walking

Cueny, D. & Deb, D. (2019). Common pediatric gait abnormalities [PowerPoint slides].

John Hopkins Medicine (2019). Toe walking. Retrieved https://www.hopkinsmedicine.org/health/conditions-and-diseases/toe-walking

Mayo Clinic. (26 April 2018). Toe walking in children. Retrieved from https://www.mayoclinic.org/diseases-conditions/toe-walking/diagnosis-treatment/drc-20378414