Understanding Toe Walking

Toe walking refers to a walking pattern in which a child walks on their toes or ball of the foot. There can be many medical reasons to account for this type of walking pattern, however often it can simply be habitual or behavioural, with no underlying cause. When there is no medical reason to account for this gait pattern, it is known as “Idiopathic Toe Walking”. This is the topic for this week’s blog.

Most children will begin walking between 12 and 15 months of age. Walking on the toes or ball of the foot is very common in children who are just beginning to walk. In the early stages of walking, children will experiment with different foot positions for walking, including walking on their toes. This pattern will usually disappear within 3 to 6 months of walking, and by around 2 years of age, they should walk with their feet flat on the ground, with the “heel-toe” gait pattern seen in older children and adults developing around 3 years of age.

There are many conditions that can cause toe walking in children such as cerebral palsy, muscular dystrophy and autism, however if toe walking persists beyond 3 years of age and the child has been assessed by a medical professional with no other medical reason being identified, they are diagnosed as an idiopathic toe walker. Idiopathic toe walking occurs in otherwise healthy children and always occurs in both feet.

Some features of idiopathic toe walking include:

  • walking on tip toes on both sides
  • constantly balancing on their toes
  • walking with straight knees
  • being able to stand with their feet flat on the ground or walk with flat feet when asked to do so
  • have a family history of toe walking
  • exaggerated toe walking when walking bare foot but better when wearing shoes
  • increased toe walking when walking on surfaces that increase sensory input, such as carpet, cold tiles and grass

Whilst the cause of idiopathic toe walking is unknown, there are many factors that may contribute to the development of toe walking. These may include:

  • altered proprioceptive processing – problems sensing the body’s position in space
  • issues with tactile processing – often an increased response to touch sensations
  • issues with vestibular processing – problems maintaining balance
  • overall body strength
  • family history – toe walking is more common in children whose parents or siblings also have a history of toe walking
  • joint hypermobility
  • flexibility of leg and foot muscles – idiopathic toe walkers not only often have tightness in the calf muscles, but also restricted hip range of motion and tightness in the iliotibial band, all of which alter their walking pattern

Walking with a normal heel-toe gait pattern is a complex motor process that relies on adequate strength and flexibility in the hip, knee and calf muscles. When there is weakness or tightness in muscles of the lower limb, the child’s gait pattern and balance can be affected. Walking with the foot flat on the ground can become uncomfortable or difficult for the child, causing them to adopt an abnormal pattern of movement, such as toe walking.

Children who walk on their toes can develop tight calf muscles and decreased movement around the ankle joint. In addition to this, the muscles on the front of their legs may become weak. This tightness and weakness will cause the child to have difficulty walking in a normal heel-toe pattern.

Toe walking in children is not uncommon, and most outgrow it. However, if your child falls into the percentage of those who don’t, what can we do about it?

What can be done about toe walking?

For children who are toe walkers, a daily home exercise program can be very helpful. The goal of the program is to stretch the calf muscles and strengthen the muscles on the front of the legs to help the child walk with a normal heel-toe pattern.

Physiotherapists commonly assess and treat children who are toe walkers. The physiotherapist will teach both the child (and their parents) how to stretch their legs, feet and toes and how to strengthen their weak muscles. This is often followed by activities to help the child use their muscles in their new lengthened position. Any issues with tactile, vestibular or proprioceptive processing will also be addressed.

In some cases, toe walking may lead to tightness or contractures of the Achilles tendon which in turn can lead to problems with how the child’s feet and legs line up. This can contribute to the development of flat arches or outwardly rotated legs in an attempt to maintain heel contact with the ground. In these cases, more aggressive treatment in the form of orthotics, serial casting or even surgery may be required. However, early identification and treatment will help to prevent this from occurring.

As long as your child is growing and developing normally, toe walking on its own is unlikely to be cause for concern, particularly as it will spontaneously resolve in most children. However, if toe walking persists over the age of 3, it can lead to ankle, hip and back problems, therefore it is important to seek the advice of your health care professional to learn about treatment options that may be best for your child.