Toe-walking: What to do about children who walk on tiptoes?

Children walk on their toes for various different reasons. Some parents look at toe-walking as a benefit to the future ballerina and other parents become very concerned when their child is constantly tiptoeing around. Frequently, toe-walking is completely benign, indicating nothing more than the child has a tendency to walk on their toes. Regardless, medical causes should be ruled out and parents should be educated as to their treatment options.

A child’s history of toe-walking will guide the process to rule out medical diagnoses and will help to guide the treatment plan. Did the child always walk on their toes or is this new? Any changes in the gait pattern will be a red flag and the child should be referred to a medical doctor to rule out Muscular Dystrophy and other diagnoses. During the evaluation, the therapist will also look for signs of spasticity in the arms and legs. Any presence of spasticity seen with passive testing or observed with movement would be red flags for undiagnosed cerebral palsy (CP). Mild CP can be missed until it presents itself with walking or coordination differences as the child ages, especially during a growth spurt.

There has been some research linking toe-walking with language disorders and other neurodevelopmental disorders. A very large number of children with autism spectrum disorder will persistently walk on their toes. Therefore, I always assess the child as a whole and ask parents about language, social and school concerns in case other referrals are necessary. Another important question is whether there is any family history of toe-walking. Family history will help guide decisions for intervention because both “growing out of it” and responding to conservative strategies are less likely.

Physical Therapy Evaluation
One of the first things a physical therapist will assess in a child who toe-walks is the child’s ankle flexibility, especially with knees straight. Can the child stand flat? If they don’t have enough ankle flexibility to walk heel-toe, that needs to be addressed prior to anything else.

Posture and strength are other important areas to assess. Muscle groups that are commonly weak are the abdominal obliques (rotators), gluteals, shoulder stabilizers and ankles. Weakness in these muscles can put a child in a forward leaning position when they stand and a slouching position when they sit. When the child in this posture initiates walking, he would naturally walk up on his toes. In addition, children who toe-walk don’t use trunk rotation while walking and may have flexibility restrictions while walking. The child with trunk tightness may also frequently w-sit over other sitting positions.

Another common piece of the puzzle for children who toe-walk are sensory organization deficits. Children should have their visual and vestibular (inner ear balance system) systems assessed. Vision is the dominant sensory system, especially in young children. Functional vision is much broader than eyesight and a lack of visual skills, such as focusing the gaze on the environment while walking, will lead children to seek out additional sensory information from other systems. In addition, children who overuse an upward gaze while walking will naturally be up on their toes. Both the vestibular and proprioceptive systems can provide some compensatory sensory input while walking. The vestibular system mediates tone, anti-gravity muscle activity and reflex activity that affects walking, balance, and ankle control and toe-walking increases the amount of proprioceptive (feedback from the muscles and joints) input the child is getting as they walk.

Physical Therapy Treatment
The options to increase ankle flexibility from most conservative to most aggressive are stretching, night splints, serial casting, and surgery. All of these options typically need to be done in combination with exercises to generalize the increased flexibility into the walking pattern. For stretching to be effective, it needs to be a prolonged stretch, which can mean night splints with an alternating knee immobilizer or standing on a wedge while watching tv for 30 minutes.

Strengthening the abdominal obliques (rotators), gluteals, shoulder stabilizers and ankles improves postural control and helps to create a more neutral posture. Activities that strengthen these muscle groups include: wheelbarrow walk, bridges (roll a car or ball underneath) , walking on heels, rollerskating/rollerblading, walking with swim fins on, swimming, climbing on playground equipment, crawling over a mountain of sofa cushions and pillows, and standing on the bed or on a sofa cushion playing catch. Once these foundations are improved, walking on a treadmill or hiking can help generalize these new movement patterns.

Another area of treatment is addressing sensory organization abilities. This includes being able to balance with eyes closed or while standing on an uneven surface. Visual-motor skills should be addressed both statically and dynamically and activities such as walking while reading or naming colors. For children who constantly use upward gaze that feeds into toe-walking, they can practice looking at a mirror or doing visual activities that are placed lower and lower over time.

Toe-walking can be a persistent habit and doctors, therapists and parents need to come together to rule out any medical concerns and to determine the most appropriate treatment strategies for the individual child. At a minimum it is important to attain and maintain appropriate flexibility of the ankles and be sure that the child’s balance reactions and gross motor skills are developing at an age appropriate level so that they can fully keep up with their peers.