For some children, walking on their toes isn’t just a playful game, but a habit known as idiopathic toe walking. Without a clear-cut cause, this condition raises questions about a child’s development, muscle function, or problems related to the brain, making it a complicated topic of discussion for doctors and parents alike. An estimated 24% of children experience toe walking; therefore, it is important to understand what idiopathic toe walking is, factors that could contribute towards the condition, and its prevalence amongst children.¹

This article will provide an overview of the definition and prevalence of idiopathic toe walking, its impact on a child’s development, and treatment options.

What is toe walking?

Toe walking is when a child persistently walks on the tiptoes or ball of their foot for an extended period of time.² During the early stages of learning to walk, it is normal for younger children to try different foot positions to help with balance. This is a normal part of development, and usually, children grow out of this habit and walk with their feet flat on the ground by the time they reach 2 years old.¹

What is idiopathic toe walking?

Definition & diagnosis

Idiopathic toe walking is a term used when an otherwise healthy child, usually over the age of 3, walks on their toes without a clear medical cause.³ Children are usually diagnosed with the condition through a process of elimination after doctors exclude other possible disorders.⁴ Toe walking can be related to some neurological and developmental conditions, such as cerebral palsy and muscular dystrophy; therefore, doctors must rule out these conditions before diagnosing a child with idiopathic toe walking.³ Diagnosis is done through medical assessments, including:

• Neurological tests- to check for any nerve damage affecting leg or foot movement
• Musculoskeletal examinations- to check for abnormalities in the foot or leg muscles
• Gait analysis- to assess the way a child walks

In some cases, imaging, such as MRI scans, might be used to check for any abnormalities in the brain or spine that could affect muscle movement or coordination when walking.⁴

Symptoms & effects

The main symptom of idiopathic toe walking is walking on tiptoes without placing the heels or other parts of the feet on the floor when standing or moving.⁵ Other symptoms seen in children include:

• Suffering from pain or tightness in their feet, particularly when walking
• Losing their balance more easily
• Running or walking slower than normal
• Having poor endurance when walking longer distances

Children who experience idiopathic toe walking could develop a shorter Achilles tendon (a thin part of tissue that connects the calf muscle to the heel), making it even more difficult to walk with their feet flat on the ground. If a child continues to toe walk over a longer period of time, this could make it difficult for them to learn how to walk normally as they grow older. Adults who experienced idiopathic toe walking as children may continue to walk on their toes and have a ‘bouncier’ walk.³

Causes

Many factors can contribute towards a child presenting with idiopathic toe walking, including:

• Weakness in the calves of the leg, causing them to lift their heels when standing for more comfort
• Sensitivity to certain textures or feelings, which can be linked to autism spectrum conditions
• A family history of toe walking or problems with posture
• Habit - some children become used to toe walking over time, causing muscle tightness, which makes it difficult for them to walk with their feet flat

Ultimately, whilst all these factors could play a role in the development of idiopathic toe walking, no single cause has been identified yet.² It is likely that children develop idiopathic toe walking through a combination of different factors or as a symptom of an undiagnosed condition(s), meaning different children can develop idiopathic toe walking for different reasons.

How prevalent is idiopathic toe walking?

Toe walking is a relatively common paediatric condition, with 24% of children experiencing the condition at some point during their childhood, according to the NHS. However, only 5-10% of children continue to do so without any underlying conditions.⁶ This means that for most children, toe walking is a temporary phase rather than a long-term concern. 

Idiopathic toe walking is more common in boys than girls, although the reason for this remains unknown.⁷ The condition is also more common in children with autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD). While not all children with these conditions have idiopathic toe walking, the association could suggest a link between sensory issues and the condition.⁸

How is idiopathic toe walking treated?

Treatment options

For most young children who experience idiopathic toe walking, medical treatment is not required, and the child will start walking normally as they grow up and develop their coordination skills.⁵

For children who continue to toe walk as toddlers, or who experience tightness in their Achilles tendon, treatment can be necessary to stretch the muscles and retrain the brain to become used to normal, heel-to-toe walking. Treatment options depend on the child’s specific symptoms and walking problems, and can include:

• Stretching and strengthening exercises to prevent muscle tightness and retrain the calf and trunk muscles in the leg
• Encouraging the child and parents to go on long walks in stiff shoes, such as walking boots, to get them used to normal walking
• Wearing supportive footwear or orthotics supports the feet and ankles to maintain proper foot positioning when walking

If standard treatments do not have any effect, children may be referred to physiotherapists, who can recommend treatments such as serial casting. This treatment involves placing a child’s foot into plaster casts, which are changed weekly, to slowly stretch out the muscles and improve the flexibility of the foot joints.

Summary & Conclusions 

Idiopathic toe walking is a common condition where children consistently walk on their toes without a clear medical reason, which can cause concern for parents. Whilst it’s normal for children to try walking in different ways when they are young, idiopathic toe walking can continue past toddler age, and may lead to long-term walking issues if left untreated. Typically, idiopathic toe walking is diagnosed by ruling out other possible causes, such as neurological or musculoskeletal issues.

The most obvious symptom of idiopathic toe walking is walking on the toes or the balls of the feet, and affected children may have trouble balancing, experience tightness in their feet and legs, or find it harder to walk for long distances. In some cases, the Achilles tendon in the leg can shorten, making it even more difficult for the child to walk normally.

Approximately 5 - 10% of children experience idiopathic toe walking at some point during childhood, with boys and children with autism spectrum disorders (ASD) or attention deficit hyperactivity disorder (ADHD) being more likely to develop the condition. In most young children, idiopathic toe walking resolves once they learn how to walk properly, so treatment is not always necessary. However, in rarer cases where idiopathic toe walking persists, treatments such as stretching exercises, supportive shoes, or serial casting can help ease any muscle pain and help correct the walking pattern. 

Ultimately, idiopathic toe walking is usually not a long-term issue or cause for concern for parents; however, it is important to monitor the condition and consider treatment if it does not improve over time. If your child continues toe walking for a long period of time or experiences any discomfort, it is advisable to seek advice from a healthcare professional to explore potential treatments.