Introduction

Most people may not be familiar with the term “toe walking”. This article will give a brief understanding of what toe walking is and the physical therapy interventions to be used to address it. 

Toe walking, as the name implies, is a movement pattern where a person walks using the tip of the toe which is similar to tip-toeing. The habit of toe walking is mostly seen among children who are learning to walk but this resolves when they get to the age of two as they develop the ability to walk normally. If toe walking goes on past this age, an underlying health issue may be suspected.¹ These can include brain injury, weak muscles in the legs, or problems with how nerves work to move the body. There are however, some cases where there is no particular cause, and as such, the condition would be referred to as idiopathic toe walking.²

If toe walking persists over time and it is not properly addressed, it can lead to further complications such as tightening of the calf muscles and tearing of the ligaments around the ankle.³

Methods exist that can help to relax tight muscles, and there are also tools that can aid in placing their feet in the correct positions when walking. These treatments, however, do not always work and surgery may be needed instead.³

Assessment and diagnosis 

It is key to understand the underlying reason as to why some people walk on their toes. Therefore, comprehensive assessments are required to determine the cause and to create a treatment plan that is specifically catered to the individual. Below are brief explanations about the assessment procedures and devices used to diagnose toe walking.

Assessment process

The assessment process involves various checks. 

An extensive physical check is conducted to identify bodily issues that may contribute to toe walking. This process typically includes examining the health and strength of the leg muscles, movement patterns, the ability to hold and position the body, and whether the individual can carry out “ ankle dorsiflexion”, which is the ability to flex the feet upwards and towards the shin.⁴

The clinician will also review the patient’s past medical records, giving a general idea of how the toe walking may have developed, any past injuries that may contribute to the condition, or other illnesses that may have led to the onset of toe walking. A comprehensive medical history may also help to rule out potential neurological and/or musculoskeletal disorders.⁴

A movement assessment is also carried out. During this process, the physician will closely observe how the child walks and whether they constantly walk on their toes. A tool that evaluates walking patterns, the Observational Gait Scale (OGS), may also be used.⁴

The toe walking tool can help to diagnose idiopathic toe walking, which, as described previously, is when an underlying cause has not been identified. This involves asking a series of questions to understand the child’s condition better and to appropriately refer the case to a specialist, should it be considered serious by the clinician carrying out the questionnaire.⁵

Finally, sensory observations may be taken in children who have sensory issues, such as autism (although this does not apply to all cases of autism). The investigation may include examining the tolerance level to several sensory signals.^6,7

Physical therapy interventions for toe walking

It is well known that children, especially those learning to walk, sometimes walk on the balls of their feet. This can become a problem if it persists and can be addressed through numerous physical treatment interventions. These interventions are beneficial as it helps to improve step pattern, strengthen the leg muscles, and can improve sensory processing difficulties.

Stretching exercises

Stretching can be very helpful in managing toe walking. Some examples include:

1. Stretching of the calf muscles. This involves stretching of the muscles of the calf, or surrounding muscles, by bending and straightening the knee. This helps to make the calf muscles more flexible as they typically are stiff in someone who walks on their toes^8,9
2. Stretching of the Achilles tendon. There are various exercises that can be used to stretch the Achilles tendon. An example are heel drops. These gently stretch the tendons which helps with their straightening and improves ankle dorsiflexion. To do this exercise, the individual takes a step on a low step with the heels of their feet partly hanging off before slowly lowering the heels down until a gentle stretch is felt⁹

Strengthening exercises

Strengthening exercises are also important for someone with toe walking to carry out regularly. For example:

1. Activities that strengthen the ankle dorsiflexor are important as they can help to strengthen the muscles that are primarily responsible for lifting the foot upwards towards the knee. One way to do this would be to pick up marbles from the ground using their toes¹⁰
2. Exercising the muscles of the limb can also help. These exercises can significantly enhance the general stability of the condition for proper movement and posture. Such exercises include squatting and crab walking⁶

Step exercises and neuromuscular training 

One form of step exercise includes encouraging the person experiencing toe walking to attempt heel-to-toe walking whilst walking backwards. Resistance bands can also be used around the heels to help with this.¹⁰

It may also be helpful to make the child watch themselves toe walking with a mirror or screen to help them observe their walking pattern, and potentially try to improve it. Walking over soft surfaces like carpet or grass can help to exert pressure to the feet, and will help to improve awareness on how to best place the feet when walking.⁶

Orthopaedic and mobility aids

Parents may consider the use of orthopaedic and mobility aids for their children to help manage toe walking. Some examples are:

1. Ankle-Foot Orthoses (AFOs). When worn, AFOs can help to provide ankle support and allow ankles to adjust properly when walking. AFOs can be worn at night as well for lasting muscle lengthening effects¹⁰
2. Shoes for children experiencing toe walking could be modified to have rigid carbon footplates. This will encourage proper foot arrangement while walking and make it difficult for the foot to bend

One-on-one treatment strategies

These strategies involve movement of the joints and massaging of the muscle tissues. This helps to repair joint movement, stability and relax muscle tissues that have been affected by toe walking habits. 

Sensory-based interventions 

These interventions are very useful when the toe walking is as a result of neurological conditions like autism. These include:

1. Physical activities that helps stimulate the body and create awareness of where the body feels signals. This can be done with weight-bearing exercises⁶
2. Improving the posture by performing balance training activities like swinging, spinning or cycling⁶

Home exercises and parent involvement to resolve toe walking

Encouraging parents of children who toe walk to be involved in carrying out home exercises will help in achieving the physical therapy goals that promote improvement in their steps or moving patterns. This can involve:

1. Daily exercise activities. Involving children in daily stretching exercises, such as stretching of the muscles around the calf, ankles and achilles tendons is a good treatment option for toe walking^8,9 
2. Proper footwear. Encouraging the use of proper footwear for toe walking is another effective way as it encourages proper gait and prevents the worsening of toe walking. Some good examples include high-top shoes that are rigid, as it is recommended to avoid soft shoes to perfect foot arrangement¹¹
3. Other activities that promote heel-to-toe walking. Actively engaging children in effective exercises like squatting and walking drills that strengthens the necessary muscles can help to improve movement pattern, posture and step alignments¹²

Summary

In summary, these interventions work well under strict guidance of a professional physiotherapist that will design their treatment plan according to their individual needs. Addressing toe walking requires a range of activities such as stretching muscles to increase flexibility and stability, gait exercises like using a treadmill, walking on uneven surfaces and hip drops to further strengthen the muscles, and orthotic tools to provide support for weaker musculoskeletal regions in the lower limbs. It is therefore important to provide early treatment interventions through physical therapy before the condition gets worse and may subsequently require surgical intervention to address. Additionally, parents of children that walk on their toes need to be heavily involved in the treatment plan as they can get the children to carry out exercises at home and provide them with the required footwear and devices that will aid their movements.