What is toe walking?

Toe walking (TW) is an abnormal type of walking when a child does not place their heels on the ground while walking or taking steps. In other words, the ball of the foot is used for walking throughout the gait cycle, without the heel touching the ground. This is commonly observed in children who are beginning to walk, but it usually disappears by the age of 2. 

The normal gait pattern develops around 22 months of age. If tiptoeing continues beyond the age of 2, further evaluation may be needed.^3,4 You may also notice your child experiencing balance issues, pain, tightness in the Achilles tendons, frequent falls, difficulty wearing shoes, and walking on the ball of the foot.^3,5)

It can result from a variety of causes or sometimes no identifiable cause, with the most frequent type being idiopathic (physiological, meaning no known medical cause) toe walking (ITW). It is not known exactly how many children are affected in the general population because not all cases are reported to physicians.⁴

In this article, we provide information about toe walking to help parents better understand this condition. Emphasis will be placed on its causes.

What is idiopathic (Physiological) toe walking?

Physiological or idiopathic toe walking (ITW), also known as habitual toe walking or associated with a congenital short Achilles tendon, is defined as tiptoeing on both legs, with or without a tight Achilles tendon. It is seen in children over the age of 3 who do not show signs of other underlying conditions. It is most frequently observed in patients who have neurodevelopmental disorders, such as autism, developmental delay, and language difficulties. It can also occur in those with neuropsychiatric disorders, such as attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), and others. It is diagnosed by ruling out other possible causes (diagnosis of exclusion).^4,6 It can resolve spontaneously, although not in all cases.¹ If a family member has been diagnosed with idiopathic toe walking, it is more likely to occur in younger family members.³

What are the medical causes of toe walking?

Toe walking that results from an underlying medical condition is called non-idiopathic walking (ITW). The most common causes are neurological, although others have been reported as well.⁴ These include:

Which neurological conditions can cause toe walking?

Disorders that affect both the central and the peripheral nervous system have been associated with toe walking.⁴ These most commonly include:

Cerebral Palsy (CP) 

Injury or abnormal brain development can cause problems such as movement difficulties, altered muscle tone, or poor posture. Toe walking happens due to muscle spasticity, which makes it difficult for the muscles to relax properly. As a result, the calf muscles tighten, making it more difficult for the child to keep the heel on the ground. In addition, the hip and knee muscles tighten, making the child place their weight on the front part of the feet.^1,3,4

Duchenne Muscular Dystrophy (DMD) 

It is a genetic condition where the muscles weaken and are replaced by scar tissue (also known as fibrous tissue). Toe walking occurs due to the weakening of the dorsiflexors, which are the muscles that lift the feet. The quadriceps, which are the thigh muscles that help stabilise the knees, are also affected. As a result, the child may walk on their toes, as this provides more strength and stability when walking.^1,3,4

Tethered Spinal Cord Syndrome (TSCS) 

It is a condition present from birth, where the spinal cord becomes attached to surrounding tissues. This leads to limited spinal cord movement, muscle weakness and difficulty walking. Toe walking can result from these issues, as the child tries to maintain their balance while walking.⁸

Spina bifida 

It is a condition where the spine does not fully develop at birth, resulting in problems with muscle control, mobility and sensation. Muscle weakness or sensory deficits could lead to toe walking.⁴

Which musculoskeletal conditions can cause toe walking?

Talipes equinovarus (clubfoot) 

This is a condition where the foot is positioned inwards and downwards. In addition, shortened calf muscles make it harder to place the heel on the ground. As a result, the child finds it difficult to place their heel on the ground while walking and instead walks on tiptoes.^4,9

Limb-length Discrepancy (LLD) 

In this condition, one leg or arm is shorter than the other. The child may walk on their toes on the shorter limb to compensate for the height difference.⁴

Can neurodevelopmental disorders cause toe walking?

Autism Spectrum Disorder (ASD) 

Toe walking has been linked to this condition, possibly due to delayed walking development or sensory sensitivities. However, a direct link has not yet been clearly established.^1,3,4,11

Attention-deficit and Hyperactivity Disorder (ADHD) 

Children with ADHD have been observed to demonstrate more frequent toe walking and shortening of the Achilles tendon than other children.^4,10

How is toe walking diagnosed?

A healthcare professional will take your child’s medical history and perform neurological and musculoskeletal examinations to determine the cause of toe walking. Examinations may include assessment of your child’s reflexes, muscle strength, tenderness, and sensation ⁽¹⁾⁽⁷⁾. In addition, imaging tests may be carried out to gain more information about your child’s condition. These include:

• X-ray: Usually used to rule out any bone abnormality in the feet and ankles, or spinal skeletal abnormalities⁵
• MRI: Usually used after an X-ray shows an abnormality, or if there is strong suspicion of a neurological problem. It is also used to check for cerebral palsy or other brain injury^5,7

Other tests might also be used, such as electromyography (EMG) and creatine kinase levels (CK), if a neurological condition is suspected. Rarely, a muscle biopsy may be used to confirm a musculoskeletal condition.^5,7

How is toe walking treated?

Managing and treating the condition depends on the child’s age, the underlying cause, and the severity of their case.⁴ Treatment options include:

• Observation: A child diagnosed with ITW is typically observed at 6- and 12-month intervals. If the condition has not resolved by age 3, other types of treatment are considered^4,5
• Nonoperative therapy: It is the preferred treatment before offering surgery. It includes physical therapy (helps release muscle tension in the affected leg muscles through stretching), leg braces (ankle-foot orthotics that keep the feet at a 90-degree angle to help stretch the muscles), serial casting (short plastic leg casts used to stretch the leg muscles, typically changed every 1-2 weeks) and botulinum A toxin injections (ease the muscle tightness and make stretching easier)^2,4,5
• Surgical therapy is considered after nonoperative measures have failed. The most common procedure is complete Achilles or gastrocnemius lengthening, which improves mobility and foot and ankle function. Other techniques may be considered depending on the patient’s case^2,4

FAQs

When should I contact a healthcare provider?

If your child continues to walk on their toes after the age of 2, or shows signs of tight leg muscles or stiffness, contact your healthcare provider.³

What is the prognosis of TW?

If your child has ITW, it will most likely resolve by age 2. However, your child’s outlook depends on the cause of their case. Some children may need additional management after surgery to prevent resuming tip-toeing, while others may require lifelong monitoring and follow-up. Consult your doctor to learn more about your child’s prognosis.^4,5

Can any complications occur from TW?

Complications can occur with persistent toe walking. These may include increased risk of falling, further tightening of the Achilles tendons, difficulty participating in sports and reduced mobility of the feet.^3,4,5

Summary

Toe walking (TW) is a condition where a child walks on the balls of their feet without putting their heels on the ground. It can be idiopathic (ITW) or non-idiopathic (non-ITW). It usually resolves by 2 years of age, but if it persists, further evaluation is necessary. ITW occurs in children over 3 years of age with no other identifiable cause. Causes are mainly neurological, but musculoskeletal, neurodevelopmental and other reasons exist as well. Diagnosis is made through taking medical history, clinical examinations and imaging tests. Treatment depends on the unique considerations of each case and involves both nonoperative and operative options.