Toe walkers may walk on their toes for just some of the day, half the day, or even all of the day. Some children only go up on their toes for a few steps but walk typically most of the time, while other children always walk on their toes and even stand still on their toes. The greater the frequency of toe walking, the greater the chances of adverse structural changes and other physical problems.
A child who walks on their toes often demonstrates stiffer legs and decreased trunk rotation while walking. They typically have an anterior center of mass, meaning that they hold their body weight more forward relative to their toes than a child who walks typically. They may have trouble keeping their balance and stopping their body quickly while walking or running. A child who walks on their toes additionally may appear to walk with a "bouncy" pattern (increased vertical propulsion).
Contrary to popular belief, toe walking often does not develop due to tight calf muscles. Calf muscle tightness typically develops as a consequence of prolonged toe walking. There are three general categories of what causes toe walking: musculoskeletal issues, a faulty neuromotor pattern, and sensory issues.
A musculoskeletal cause of toe walking is occasionally due to shortened/tight calf muscles, but is most often due to weakness in the core muscles. Babies born prematurely may be predisposed to shortened calf muscles due to missing out on the prolonged lengthening of the calf muscles that occurs during the last four weeks of gestation. Children with neurological conditions such as cerebral palsy may also develop shortened calf muscles over time, leading to increased incidence of toe walking when they begin walking. Children with core muscle weakness may toe walk to avoid having to activate their core muscles while walking. Toe walking may be easier for children with core weakness because they can lock out their knee and ankle joints for stability instead of actively using their core muscles to stabilize their body. This pattern then leads to more core weakness because the core muscles are not getting activated with each step.
A neuromotor pattern can be thought of as a set of instructions the brain gives the body in order to complete a movement. Neuromotor patterns are learned and developed as we learn new skills. A faulty neuromotor pattern that is learned when a child is young may cause their brain to believe that pattern is the correct movement pattern to continue using. A child that frequently moves their body into an extension pattern to avoid the discomfort of reflux or other gastrointestinal issues may then walk in this extension position, which includes ankle plantarflexion (toes/foot pointed down)/toe walking, as well. Additionally, a baby who is placed in a jumper device or device similar to an exersaucer for more than 30 minutes each day may develop a movement pattern including toe walking because these devices put them in a standing position with only their toes touching the ground.
Some children walk on their toes to either increase or decrease the sensory input their body is receiving. Children who are sensitive to certain surfaces may walk on their toes to limit the surface area of their feet that touches the ground. Alternately, children who seek out more sensory input than other kids may walk on their toes because it changes the way they feel the weight of their body. Walking on their toes may give sensory-seeking children greater sensory input due to the anterior weight shift that occurs with toe walking. If children begin walking on their toes after age three, it is often due to sensory issues and trouble with the various sensory systems working together.
Risk Factors for Toe Walking
The following factors increase the chances of a child walking on their toes:
Muscle weakness in the core
History of prematurity
History of low birth weight
History of learning disabilities, Autism Spectrum Disorder, and/or speech delays
Moderate-severe calcaneal valgus (ankles that collapse inward)
Skipping crawling as a baby
Outgrowing Toe Walking
Babies may walk on their toes initially while learning to walk (inconsistent toe walking, not every single step), but they should achieve a more typical gait pattern within 6 months of walking. If they are on their toes a majority of the time while just starting to walk or if they are still on their toes after 6 months of walking, they most likely will not outgrow the toe walking without intervention that addresses the root cause. A little bit of toe walking can be normal (but not ideal) while learning to walk, but more frequent toe walking or toe walking that persists after 6 months of walking is not typical. A child is additionally less likely to outgrow toe walking if they demonstrate other signs/symptoms such as sensory challenges or vestibular issues (gets carsick often, strongly dislikes spinning/motion, likes spinning/motion more than typical, etc.).
Consequences of Persistent Toe Walking
Toe walking is not good for the musculoskeletal system biomechanically. Toe walking requires greater than 50% more energy to do than typical walking and it causes further issues with muscle function, bone structure, and balance. Persistent toe walking can cause:
Wider than normal forefoot due to hypertrophy of forefoot bones, leading to difficulty fitting the foot into shoes and an unstable foot structure
Decreased heel bone size and curled toes, leading to difficulty finding shoes that fit appropriately
Increased frequency of foot and ankle injuries
Increased risk of falls and clumsiness
Joint pain in the feet, ankles, knees, hips, and spine
Ankle joint contractures
Impaired motor skills and difficulty keeping up with peers
Decreased endurance during physical activities
Weak core muscles
Medical treatments for toe walking include Botox injections and achilles tendon lengthening surgery. These treatments are typically reserved for severe cases and are used as a last resort. Botox injections are used to relax the tight calf muscles to allow for easier stretching, however, these injections also greatly decrease the strength of the calf muscles. Botox is often followed by aggressive use of braces or serial casting to stretch out the tight calf muscles. Achilles tendon lengthening surgery lengthens the tendon that attaches to the tight calf muscles, increasing ankle range of motion. Conservative treatment should be trialed for at least 6-12 months before these options are considered.
Physical/Occupational Therapy Treatment
Treatment for toe walking focuses on a few core concepts. These concepts include lengthening the shortened muscles, strengthening leg and core muscles, and posterior weight line training. Typically, the gastrocnemius, hamstring, and lumbar spine extensor muscles all need to be lengthened due to their prolonged shortened position used during toe walking. Strengthening activities will often have a strong focus on the abdominal, gluteal, and ankle dorsiflexor muscles. Posterior weight line training will help the child learn to shift their weight backward onto their heels while standing and walking instead of on their toes. Treatment may additionally include shoe inserts, orthotics, Kinesiotape, and other modalities as needed. If there is a sensory component to the toe walking, occupational therapy will be involved to help address the sensory needs. Treatment for toe walking has the best success rate when began as early as possible.
1. Ritchie-Persaud L. Therapeutic Evaluation and Treatment of Toe Walking (Pediatric Equinus Gait). Online Presentation: 2021.
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