Overview 

It is common to observe toddlers who have just started walking on either the balls of their feet or their toes; this condition is known as toe walking. For many children, toe walking is a normal development  phase typically resolves on its own  independently as they develop and improve their walking skills. However, for some children, toe walking can become a habitual behavior that persists beyond toddlerhood. While toe walking is frequently observed  in children around age two, most will transition to a heel-to-toe walking pattern as they grow older. If the habit persists after the age of two, then it might be a sign of some other medical condition, which requires investigation. Toe-walking gait is quite common in children even till the age of five. The most common and detectable symptom is walking on toes or balls of the feet. Flat feet is another common symptom, which is a decrease in balance, more falls than normal, constant pain, and even difficulty in sports activities.²

Causes

There are various reasons why toe walking occur in children, but the most common being developing a habit of walking in that manner. Some other medical conditions can also lead to toe walking in children. 

Some of these reasons are¹

1. Idiopathic toe walking - this is the most common, which is caused without any medical condition and is diagnosed easily
2. Cerebral Palsy- this disorder is caused by toning of muscles, movement disorders, or any posture deformities caused due to injury
3. Achilles tendon - this is the connection between the back of the heel bone and the muscles in the lower part of the leg, and if these tendons are short, it prevents the heel from touching the ground
4. Autism- due to a child's inability to process their sensory parts, it may lead to toe walking.
5. Muscular dystrophy- this is a genetic disorder where the muscles get weak and leading to toe walking¹

Diagnosis and treatment

There are different diagnostic steps to identify the cause of toe walking.²

1. Medical history, which includes assessment of muscle tone, coordination, and even reflexes 
2. The genetic muscular dystrophy is the only reason if it is suspected
3. Gait analysis is the observation of the walking pattern of a child in depth and then identifying the abnormalities and causes
4. Electromyography (EMG) is an exam where a thin electrode needle is inserted into the muscle of the leg. This measures the electrical activities in muscles and in nerves3 
5. If conditions such as cerebral palsy or autism are detected in a child, they are advised to take the neurological exam 

Treatment depends on the cause of the situation. For instance, if the child is walking on their toes due to habit, this problem can be rectified with time, and they will outgrow the behaviour, and no treatment is usually necessary.¹ But for children who have various other reasons for toe walking, some treatments include physical therapy where stretching of foot muscles and legs can improve the gait of the child and normalise the walking pattern. Another treatment is splints, which are often known as leg braces. If the condition occurs when both the above treatments are not successful, then casting below the knee is done, which improves the toes' ability to bring them towards the shin.² The last option, if all other options fail, is the surgery where the doctors stretch and increase the length of tendons at the back. 

Discussion

Although toe walking is very common among children and usually develops over time, as the child grows, it is crucial to monitor the  the foot posture and movement of the child, as sometimes it could be more than just a habit. If there is any family history or medical history of a child, then it is important to consult the doctors in time to prevent any complications. It is crucial to be aware of such problems and what treatments can be done. To prevent it by stretching the achilles tendon to reduce toe walking, and even after observing the habit of toe walking, even detected footwear can be used for children to prevent the situation.² With rapid  development in science and technology, there would be more convenient options for the treatment and diagnosis of toe walking, which would help in not only early detection of the situation but also better prevention methods can be found and used. So it is important to talk to doctors if such a situation is observed and correct treatment is provided. 

Summary

Toe walking is common in toddlers and often resolves naturally as walking skills improve. However, if it persists beyond age two, it may indicate an underlying condition such as cerebral palsy, autism, muscular dystrophy, or a short Achilles tendon. Diagnosis usually involves medical history, gait analysis, and sometimes specialised tests like EMG. Treatment depends on the cause and can range from observation and physical therapy to splints, casting, or surgery in severe cases. Early recognition and medical consultation are important to ensure proper management and to prevent long-term complications.