Introduction

Why do some children walk on their toes? For most children, learning how to walk is a natural transition. However, some children persistently walk on their toes instead of adapting to the typical heel-to-toe gait.¹ While this may seem harmless or even cute in children, persistent toe walking over the age of 3 may suggest an underlying condition.¹ 

One of the primary causes of toe walking is a shortened Achilles tendon.¹ The Achilles tendon, located at the back of the lower leg and connecting the calf muscle to the heel bone, plays a key role in the movement of the feet.² When the calf muscle contracts, the Achilles tendon pulls on the heel, facilitating walking. However, if the muscle-tendon combination is too short, the heel can’t make proper contact with the ground, forcing the child to walk on their toes.^{1, 2}

To treat toe walking, Achilles tendon lengthening is the common procedure to recover a normal walking pattern.¹ This can be achieved through non-surgical methods that attempt to stretch the Achilles tendon naturally and surgical procedures that require professional intervention. If one wants to know more about these procedures and how they can help, you’re in the right place. 

What causes toe walking?

The majority of children's toe-walking is idiopathic, meaning that there is no known reason why it occurs.³ Many children who exhibit this walking pattern quit in early childhood.¹ However, in other cases, toe walking is due to the tightness of the muscles and tendons, either from birth or as a learned habit.²

In some instances, toe walking may be a symptom of more serious underlying conditions, including brain or muscle disorders such as cerebral palsy, Duchenne muscular dystrophy and even autism.^1,3

If the child continues to walk on their toes past the age of 3, it is important to consult a doctor.³ Chronic toe walking can lead to contractures in the Achilles tendon, altered foot shape and other functionality issues, making early diagnosis and intervention crucial.¹

How is toe walking diagnosed?

A medical professional will study your child’s medical history and observe how the child walks, looking for abnormalities.² Some of the things they examine are:²

• How your child walks 
• Range of motion 
• Issues with your child’s feet or legs 

Other tests may be required to see if the child has a problem with their nervous system:^1,3

• Testing your child’s reflexes 
• Testing muscle strength 
• Other technical tests, such as MRI or creatine phosphokinase test 
• Silfverskiöld Test 

Non-surgical treatment options 

In most cases, doctors will recommend non-surgical treatments as the first approach before considering surgery. However, these treatments have varied success rates, and many children eventually return to toe walking after a short period.¹

Physiotherapy

A physical therapist will suggest calf muscle stretching exercises.²

Braces and orthotics

The doctor may recommend an ankle-foot orthosis (AFO), a type of brace designed to stretch the calf muscles and hold the foot at a 90-degree angle.⁴ This helps encourage a more natural walking pattern. AFOs are typically worn for several months and are considered the most effective non-surgical treatment for toe walking.^2,4

Botox

Botox (botulinum toxin type A) is a muscle relaxant that can temporarily reduce calf muscle tightness, making it easier to achieve a normal walking pattern.² It is most commonly recommended for patients with neurological conditions. By relaxing the muscles, Botox allows for more effective bracing or casting, helping to gradually stretch the Achilles tendon and improve mobility.²

Serial casting 

Serial casting is a treatment where a doctor applies a series of short-leg walking casts over several weeks to gradually stretch and lengthen the calf muscles and Achilles tendon.^2,4 

Types of tendon lengthening surgeries

Tendon lengthening surgery is the most effective treatment for toe walking, offering improved ankle mobility and the lowest relapse rates compared to other treatment methods. There are various surgical techniques for tendon lengthening, and the best approach depends on the individual case. However, surgery is typically only recommended when non-surgical treatments have been unsuccessful.^{2, 3}

Tendo-achilles lengthening - zone III

Achilles tendon lengthening (TAL) is the most common surgery for toe walking. It involves making small incisions in the Achilles tendon, allowing it to stretch and improve flexibility. This helps restore a natural heel-to-toe walking pattern. There are two main types of TAL procedures:

Z-plasty

Z-plasty is the most common TAL surgery, especially for severe cases where more lengthening is needed. It is done as an open surgery, where a Z-shaped incision is made in the Achilles tendon to carefully stretch and lengthen it.⁵ First, a long cut is made down the centre of the tendon, followed by small Z-shaped cuts that allow for controlled lengthening.⁵ Once the ankle is moved into a natural position, the tendon is stitched back together to heal properly.⁵

Percutaneous TAL

Percutaneous TAL is a minimally invasive procedure used to lengthen the Achilles tendon with smaller cuts and a faster recovery. During the surgery, the doctor makes three small horizontal incisions along the tendon in an alternating pattern.⁶ As the cuts are made, the foot is gently flexed into a natural position, allowing the tendon to stretch and lengthen.⁶ Because the incisions are small, this method reduces scarring and shortens recovery time compared to open surgery.⁶

Gastrocnemius recession - zone I

This procedure targets only one of the two calf muscles (gastrocnemius muscle), helping the Achilles tendon stretch more easily and improving ankle flexibility. If the other calf muscle (soleus muscle) is also tight, a zone II surgery may be needed to lengthen both muscles for better movement.⁵

Endoscopic gastrocnemius recession

A small incision is made on the inner side of the calf, and a tiny camera (endoscope) is inserted to help the surgeon see the muscle. The gastrocnemius muscle is carefully cut, allowing it to stretch and let the heels lower into a natural position.⁷ This minimally invasive procedure results in smaller scars and a quicker recovery compared to open surgery.⁷

Intramuscular gastrocnemius recession (open technique)

A small incision is made on the inner side of the calf, and a part of the calf muscle covering (fascia) is carefully cut in a V shape or straight line. This helps the muscle relax and stretch, making it easier to move the ankle more freely.⁸

What to expect after surgery

Immediately after surgery 

As the anaesthetic wears off, one could feel nauseous or throw up within the first 24 hours, and this is very normal.⁹ Keeping your foot elevated for the first 48 hours will help reduce swelling and discomfort. It’s also a good idea to wiggle the toes periodically to promote circulation and prevent stiffness.⁹

Recovery timeline

After Achilles tendon lengthening surgery, it usually takes three to six months to fully recover. However, most children can return home the same day after surgery with a cast on their foot for 4 weeks: ⁹

• Weeks 1-4—The child will wear a cast to protect the tendon as it heals
• Weeks 5-6—The cast is replaced with a walking boot, and partial weight-bearing is gradually introduced
• Weeks 7+—The child can transition to regular shoes and usually begins physiotherapy to restore strength and flexibility

To manage discomfort, pain medications like ibuprofen or stronger prescriptions may be recommended during the recovery period.⁹

If both feet require surgery, the second procedure is typically scheduled 2.5 months after the first.⁹

Risks and long-term outcomes 

If someone is considering Achilles tendon lengthening surgery, it’s important to understand both the benefits and potential risks. While this procedure is generally safe, complications can occur. Being aware of what to anticipate will help you avoid risks and get ready for recovery:²

• Sural nerve injury—The sural nerve is located on the outer side of the Achilles tendon. You can feel numb, tingly, or in pain if it gets damaged during surgeryWound healing issues 
• Overlengthening or tearing of the Achilles tendon—During surgery, the tendon can get over-lengthened and even rupture
• Weakness when pushing off while walking 
• Loss of ankle plantar flexion-knee extension couple

What about toe walking recurrence?

For some individuals, especially those with severe toe-walking, the condition may partially return over time, although it is an extremely rare occurrence.³

Summary

Toe walking is common in toddlers when they begin to walk and is typically not a reason for worry. However, if the child continues toe-walking past the age of 3, it’s a good idea to see a doctor. Persistent toe walking is often linked to a shortened Achilles tendon, so treatment usually focuses on stretching or lengthening the Achilles tendon, with surgery being considered only if other treatments don’t work. A doctor can help determine the best approach for the child’s needs.