What Is Toe Walking

  • Haajar Dafiri BSc (Hons), Biochemistry, University of Wolverhampton, UK
  • Raadhika Agrawal Bachelor of Medicine and Bachelor of Surgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India

Introduction 

Definition 

As suggested by its name, toe walking1 is when children walk on their toes and balls of their feet without letting their heels touch the ground

Prevalence and common age of onset

Toe walking is prevalent and quite common,1 affecting over 2% and 41% of five-and-a-half-year-old children who are still developing or have developmental delays/disorders, respectively. 

Importance of understanding toe walking 

It is important to understand toe walking because although it is common and normal in children under the age of 2, it becomes a cause of concern once children continue to toe walk past the age of 2 as it could suggest that they have an underlying medical condition. Examples of these medical conditions include:

  • Brain disorders e.g. cerebral palsy
  • Muscle or nerve disorders e.g. muscular dystrophy
  • A spinal cord abnormality
  • Autism spectrum disorder (ASD)

Types of toe walking 

There are two main types1 of toe walking:

  1. Idiopathic or habitual toe walking: this is when children walk on their toes for no apparent medical or orthopaedic reason. Most children outgrow this
  2. Neuromuscular toe walking: this is when children walk on their toes due to neuromuscular conditions such as:
    • Cerebral palsy
    • Muscular dystrophy 
    • Autism spectrum disorder (ASD)
    • Spinal cord abnormality 

Signs and symptoms of toe walking 

In addition to walking on their toes and balls of their feet, children with toe walking often present with the following signs and symptoms:1 

  • Regular falls
  • Difficulty with balance and coordination 
  • Difficulty wearing shoes: especially sports footwear for ice skating, for example
  • Difficulty engaging in exercise, sports, or other recreational activities 
  • Difficulty heel walking with toes up in the air
  • Pain and tightness in heel cords 

Causes of toe walking

Several factors may cause1 toe walking including: 

  • Habitual or idiopathic (unknown) factors: this is the most common cause of toe walking. It occurs when children walk on their toes and balls of their feet out of habit for no apparent medical or orthopaedic reason. Most children outgrow this 
  • Developmental factors: some children may be born with a shortened Achilles tendon and/or very tight calf muscles which makes it very difficult and even impossible for them to get their heels touching the ground. The shortened Achilles tendon can shorten further over time and cause more pain and gait issues
  • Medical conditions: as mentioned above, toe walking can affect some children with medical conditions, particularly neuromuscular conditions such as:
    • Cerebral palsy
    • Muscular dystrophy 
    • Autism: interestingly, research1 has demonstrated that over 9% of children on the autism spectrum walk on their heels and balls of their feet compared to 0.5% of children without autism. The reason behind this is, however, unclear to date  
    • Spinal cord abnormality 

Diagnosis 

A healthcare provider will diagnose1 a suspected patient with toe walking by performing a series of tests in the following order:

  1. Physical exam: the healthcare provider will check the patient’s feet and legs and look for signs of gait and coordination issues  
  2. Medical history: the healthcare provider will check if the patient has medical conditions specifically autism, cerebral palsy, and/or movement disorders such as muscular dystrophy as these increase the risk of having toe walking
  3. Neurological exam: the healthcare provider will check the functioning of the patient’s nervous system by testing several neurological aspects including: 
    • Cognition
    • Movement, balance, and coordination
    • Reflexes
    • Muscle strength 
    • Ability to perceive sensations in arms and/or legs

Management and treatment 

To date, management and treatment for toe walking depend primarily on the children’s age and how severe their toe walking is, as well as the cause of toe walking

However, the most common current management and treatment options1 for toe walking include:

  • Physical therapy: this may include serial casting which is an approach that involves the affected child wearing walking casts for several weeks to increase both calf and tendon muscle strength and length 
  • Leg braces (ankle-foot orthotics): calf and tendon muscle strength and length of toe walkers may also be improved by wearing a plastic leg brace that keeps their foot at a 90 degree angle 
  • Observation: this is when a healthcare provider waits for a maximum of 6 months to see if the child’s toe walking improves on its own with time 
  • Botulinum A toxin (Botox): Botox injections may be recommended to help loosen and stretch tightened calf muscles 

Other less common treatments1 for toe walking include: 

  • Surgery: specifically if the child is older than 5 years
  • Prism lenses: to improve spatial position 
  • Vestibular-sensory therapy: this may be particularly helpful for children with toe walking who are on the autism spectrum. The vestibular system is important for controlling balance, coordination, spatial orientation, and position.  Children with autism are suggested to have a dysfunctional vestibular system. The main aim of vestibular-sensory therapy is to stimulate the vestibular system so that children with autism can process vestibular information more efficiently and have better motor control and balance 

Prognosis and long-term outlook

The prognosis and outlook1 of toe walking depends on its cause. Children with idiopathic or habitual toe walking can make a full recovery and walk flat-footed after treatment. However, some children including those with neuromuscular conditions may not recover fully even after surgery and need to manage their signs and symptoms for life.  

Summary 

Toe walking is a common condition that causes young children to walk on their toes and balls of their feet. The majority of children outgrow toe walking (idiopathic or habitual toe walking) whilst some never fully recover due to neuromuscular conditions such as autism spectrum disorder, muscular dystrophy, cerebral palsy, and spinal cord abnormality. 

In addition to neuromuscular conditions, toe walking may also be caused by developmental problems during birth such as a shortened Achilles tendon or occur due to an unknown cause. 

Toe walking is usually not a cause of concern in children under the age of 2 but becomes a serious issue once children continue to toe walk beyond the age of 2. 

Toe walking mainly affects balance, movement, and coordination but also increases the risk of falls and makes it very difficult, if not impossible, for children to engage in sports or recreational activities. It can, therefore, have a huge impact on the affected child’s mental health and wellbeing, making early intervention a necessity. 

At present, toe walking is mainly diagnosed via a physical examination, medical history check-up, and neurological examination. 

The main current non-surgical management and treatment options for toe walking include:

  • Physical therapy
  • Leg braces
  • Observation (‘’wait and see’’ approach)
  • Botulinum A toxin (Botox) injections 

Less common management and treatment options for toe walking include:

  • Surgery: mainly for children with toe walking over the age of 5
  • Prism lenses
  • Vestibular-sensory therapy: particularly for children on the autism spectrum as they tend to have a dysfunctional vestibular system, making them more prone to falls, gait, and coordination issues 

References 

  1. Cleveland Clinic. Toe Walking [Internet]. [cited 2023 October 09]. Available from: https://my.clevelandclinic.org/health/diseases/21017-toe-walking
This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Haajar Dafiri

Bachelor of Science with Honours – BSc (Hons), Biochemistry, University of
Wolverhampton, UK


Haajar Dafiri is a recent First Class BSc (Hons) Biochemistry graduate from the University of Wolverhampton with over 4 years of academic writing experience.
She has professional experience working in both labs and hospitals such as LabMedExpert and the NHS, respectively. Due to her ‘’outstanding undergraduate’’ academic achievements, she was awarded both the Biosciences Project Prize and the Biochemical Society Undergraduate Recognition Award.

From a young age, whenever words and science were involved, Haajar eagerly followed. Haajar particularly enjoys diving deep into intricate research articles and interpreting, analysing and communicating the scientificfindings to the general public in an easy, fun and organised manner – hence, why she joined Klarity. She hopes her unique, creative and quirky writing style will ignite the love of science in many whilst putting a smile on their faces.

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Klarity is a citizen-centric health data management platform that enables citizens to securely access, control and share their own health data. Klarity Health Library aims to provide clear and evidence-based health and wellness related informative articles. 
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