Toe walking in children occurs when they walk on the balls of their feet without letting their heels touch the ground. It is a beginner-friendly walk, which they will eventually outgrow. Toe walking usually stops after three years of age. After this age, the child can walk in the normal toe-to-heel pattern (1) (2).
But, sometimes, a child may toe-walk even after three years of age. This may be due to an underlying problem. Timely detection and treatment of this cause are essential.
Read on to know more about the reasons, complications, and treatment options for toe walking in children.
Signs And Symptoms Of Toe Walking In Children
Toe walking has some features that may clearly distinguish it from other walking patterns. Children with this walking pattern (3)
- Walk on their toes on both sides.
- Balance on their toes, and their heels do not touch the ground while walking.
- Walk with straight knees.
- Can stand with their feet flat on the ground.
- Struggle to walk with their heels down.
- Face difficulties walking with shoes.
Children who walk on their toes continuously may face issues participating in sports and recreational activities (1). Even if the child may not have any issues, parents may worry about their child’s continued toe walking and its effects on their future life. Hence, knowing why a child walks on their toes is necessary.
Note: Some children may walk on their toes for up to six to seven years. In most cases, this may happen due to the habit of walking on their toes from a young age (4).
Why Do Children Toe Walk?
According to Dr. Megan Eileen Shimkaveg, pediatrician, University of Maryland St. Joseph Medical Center, “For children who are learning to walk, walking on their toes or on the balls of the feet is not uncommon. Most times—as in the case of my three-year-old—it’s just a cute habit. Though she’s able to walk flat-footed and fully flex her feet and her calves, she just likes to “walk like a ballerina.” If your child is growing and developing normally and can fully flex and extend the feet and calves, can stand and walk normally, parents shouldn’t be overly concerned. Most children, as they age and become more physically active, naturally outgrow it.”
In most cases, toe walking is idiopathic, meaning no apparent reasons are known. Some children with idiopathic toe walking can walk with flat feet when asked to do so (2).
Idiopathic toe walkers often tend to tiptoe when barefoot or while walking on surfaces with increased tactile sensations, such as cold tile and grass. These children don’t generally have tightness in their leg muscles and Achilles tendons, but they develop it as they get older.
The parents need to be concerned if the child persists walking on toes as it may be due to some pathological reasons. In some cases, toe walking may happen due to underlying anatomical and neurological reasons, such as (1)
- Short Achilles tendons
- Cerebral palsy
- Low muscle tone0
- Muscular dystrophy (progressive loss of muscle mass)
- Spinal cord abnormality
- Developmental abnormalities, such as dysplasia of the hip
Children with autism spectrum disorder also frequently walk on their toes. However, their walking on the toes is believed to be due to sensory issues. Toe walking is more common in boys than girls and may often run in the child’s family (4).
Diagnosing Toe Walking
“If your child cannot fully flex his or her feet or calves or can’t stand or walk normally, you should talk with your pediatrician. She or he can do a simple physical exam to determine if there may be a problem,” suggests Dr. Shimkaveg.
To understand why a child is toe walking, the doctor will first gather the child’s medical and family history and may then do the following tests.
1. Physical examination: The doctor will ask the child to walk on a flat foot and then on their toes. Doing this will help the doctor check for abnormalities in the legs, tightness in the leg muscles, and range of motion in the hips and knees. The doctor will ascertain if there is an issue with the muscles. The doctor is also likely to ask the following questions to the parents and the child (1).
- “What complications is the child facing?”
- “At what age did the child start toe walking?”
- “Is there a family history of toe walking?”
- “Is toe walking present on one side or both?”
- “Can the child walk flat-footed if asked to?”
- “Does the child have additional complaints, such as foot or leg pain or weakening of the leg muscles?”
Response to these questions will help the doctor make suggestive findings, based on which they may refer the child to a neurologist or orthopedist. These specialists may then order additional tests, such as neurological tests, to confirm the diagnosis.
2. Neurological tests: Depending on the child’s age, developmental level, and suspected abnormalities, the doctor may perform some neurological tests.
These tests will help the doctor know if a neurological issue is causing the child to toe walk. During the exam, your doctor will
• Check if there’s excessive tightness of the legs and arms muscles.
• Check the strength of the major muscles.
• Check the child’s response to stimuli or reflexes by tapping different points on the body using a rubber hammer or fingertip.
If no neurological cause is identified, the doctor may order X-ray or CT and MRI scans to rule out any anatomical abnormalities.
How Is Toe Walking Treated?
“In cases where toe walking is a habit, gentle, regular reminders to “walk on your feet” can be a great way to encourage flat-footed walking. Calf and Achilles tendon massages are great for helping to relax the muscle and tendon to allow for normal walking. They’re also soothing for little ones and can be a great bonding time with your child,” notes Dr. Shimkaveg.
The treatment course depends on the child’s age and their ability to walk flat-footed. For instance, if a child between two and five years can walk flat-footed, the treatment will always be non-surgical (1).
1. Observation: In the initial stage of treatment, the doctor will monitor the child through regular check-ups for an estimated time, as most children with idiopathic toe walking outgrow their habit or behavior of toe walking over time.
2. Physical therapy or exercises: The child may be asked to exercise at home regularly. The doctor or physical therapist will ask the child to stretch the muscles and tendons in the calf to reduce the muscle tightening and help the child walk with a toe-to-heel pattern.
They will also be asked to stretch their ankles to improve their range of motion and do lower body exercises to strengthen the back, hips, and legs.
Despite these, If the child’s walking style doesn’t seem to improve or deteriorates in any way, the doctor may suggest the following.
3. Serial casting: Serial casting is the procedure where the doctor may apply several walking casts on the child’s legs for several weeks. This may help stretch and lengthen the calf tendons and muscles, allowing the child to outgrow the toe walking habit. Serial casting will gradually correct the deformity.
4. Bracing: If the doctor feels that serial casting does not suit your child, they may brace their lower leg and foot with an AFO (ankle-foot orthosis). An AFO is a plastic-based brace that holds the leg and foot at a 90-degree angle. The child needs to wear it for 24 hours or at least during awake hours. It helps stretch and lengthen the muscles and tendons in the leg and control motion.
Unlike casts, braces typically stay on the child’s legs for months. In some cases, the doctor may put a night splint on the child’s leg, which the child must wear even while sleeping to keep the muscles stretched.
5. Botox therapy: If the child toe walks due to a neurological abnormality, such as an increased muscle tone, the doctor may give them a botox injection. Botox is a botulinum-A toxin that can temporarily weaken the calf muscles, thus allowing them to stretch more easily during casting or bracing.
In children who continue to walk on their toes beyond five years, walking flat-footed may not be possible as the Achilles tendons and calf muscles get too tight. For such cases, the doctor may recommend surgical treatment to lengthen the Achilles tendons, which will improve range of motion and facilitate better ankle and foot function.
There are several techniques that the doctor can use to lengthen different areas of the tendon. The doctor will discuss the best option for your child. Once the procedure is done, the doctor will place a cast, which will typically stay for four to six weeks.
For a child to learn to walk normally, they must do the home exercises regularly after their surgical or non-surgical treatment is over. To ensure they exercise regularly, keep motivating them and make exercising fun.
Complications Of Toe Walking
In most cases, timely detection and prompt treatment of toe walking can help a child walk normally. However, if the treatment doesn’t work and the child continues to walk on their toes, it can cause complications, such as (3) (5)
- Tightening of the Achilles’ tendons and calf muscles.
- Decreased movement of ankles.
- Child has an awkward gait
- Weakening of the muscles on the front of the legs.
- Pain due to undue stress on the knees, lower back, and hips.
- Undue pressure on the knees can cause knee problems at a later age
- Risk of falling and injury due to lack of coordination.
With such issues, the child will have difficulty walking on their heels and participating in peer activities, further impacting their self-esteem and confidence. “Anticipatory guidance for parents should focus on the natural resolution of toe walking by age three years, and for those experiencing toe walking years longer, the overwhelming resolution by age ten (50-79% depending on the study),” notes Dr. Chelsea Johnson, associate lead of pediatrics at K Health.
Frequently Asked Questions
1. Is toe walking a disability?
Toe walking isn’t a disability. Instead, it’s a normal child gait that self-resolves by three years (2). However, a child continuing to walk on their toes for longer indicates an underlying problem.
2. Do children with ADHD walk on their toes?
According to a study, children with ADHD more frequently have idiopathic toe-walking than those without ADHD (6). However, toe-walking by itself isn’t a sign of ADHD. Instead, it’s a normal walking pattern that self-resolves by age three in many children.
3. How long does it take to correct toe walking?
There’s no set time frame for correction of toe walking. The time it takes to correct toe walking depends on its cause and the treatment modality used to correct the condition.
Toe walking in children is common when they begin to walk, and it disappears after they learn to walk. In toe walking, there is no contact between the heel and ground, and most children outgrow it by age two. You may seek medical care if your child continues to walk on their toes since it can be due to underlying conditions such as short Achilles tendon, cerebral palsy, spinal cord abnormalities, and muscular dystrophy. Long-term toe walking can also cause abnormal gait and weakening of the front leg muscles. The treatment may vary depending on the underlying condition.
- Walking on toes on both sides, heels not touching the ground while walking, and standing with flat feet are a few features of toe walking.
- The cause for toe-walking remains unknown in most cases.
- However, in some cases, anatomical or neurological issues, such as low muscle tone, cerebral palsy, and hip dysplasia, could be the cause.
- The treatment for toe-walking will mostly be non-surgical and relies on the child’s age and the underlying cause.
- If treatment doesn’t work and the child continues to walk on toes, complications, such as decreased ankle movement and awkward gait, could occur.
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- Víctor Soto Insuga et al.; [Do children with attention deficit and hyperactivity disorder (ADHD) have a different gait pattern? Relationship between idiopathic toe-walking and ADHD].