Toe walking is a pattern of walking in which a child walks on the balls of his or her feet, with no contact between the heels and ground. Toe walking is common in children who are learning to walk. After the age of 2, however, most children outgrow toe walking and begin to walk with a normal heel-to-toe pattern.

In very rare cases, continuing to toe walk after age 2 may be a sign of an underlying medical condition. In the vast majority of cases, however, persistent toe walking is “idiopathic,” which means that the exact cause is not known. Older children who continue to toe walk may do so simply out of habit or because the muscles and tendons in their calves have become tighter over time.

Treatment for persistent toe walking often involves a period of casting or bracing with orthotic splints to help stretch the muscles and tendons in the calves and encourage a normal gait.

Anatomy

Your calf is formed by two major muscles. They are:

• Gastrocnemius muscle – This is the larger calf muscle. Its two parts form the bulge that is visible beneath the skin.
• Soleus muscle – This smaller, flat muscle lies underneath the gastrocnemius muscle.

Both muscles merge at the base of the calf, where they transition into becoming the Achilles tendon. The Achilles tendon then inserts into the calcaneus (heel bone). When you contract your calf muscles, the Achilles tendon pulls on your heel.

In some children who toe walk, this muscle-tendon combination may be shorter at birth, or may shorten over time, which prevents the child from touching his or her heels to the ground and walking flat-footed. However, in most children who toe walk, the muscle-tendon combination is long enough that the child is able to walk with his or her heels down if reminded to do so.

Cause

As we touched on earlier – for the vast majority of children, toe walking is “idiopathic,” which means that the exact cause is unknown. When these children are assessed by a doctor or physiotherapist, their physical exams and neurological tests are normal.

Medical Causes

In a smaller number of cases, persistent toe walking can be a sign of an underlying medical condition, such as:

• Cerebral palsy
• Muscular dystrophy
• A spinal cord abnormality

Although children with autism-related conditions toe walk more frequently than children who are developing normally, there is no direct link between the two conditions, and their toe walking may be sensory-related.

Symptoms

Most young children who walk on their toes are able to walk flat-footed when asked todo so. However, many older children who continue to toe walk (usually those over the age of 5) are not able to walk with their heels down. These children may complain about problems wearing shoes or participating in sports or recreational activities that involve wearing boots, roller skates or ice skates.

Some children who toe walk have no specific complaints, but their parents are still concerned about the impact their walking pattern may have on their future function as teenagers and adults.

Other tests

Idiopathic toe walking is a diagnosis of exclusion, meaning that no other problems can be identified from your child’s medical history and physical exam. For this reason, specific tests such as X-rays, CT and MRI scans, and nerve and muscle tests involving electrode patches or needles are not usually ordered.

Treatment

Treatment for toe walking depends on a number of factors, including:

• The age of the child
• Whether the child is able to walk flat-footed

Non-surgical Treatment

For children who are 2 to 5 years old and able to walk flat-footed, initial treatment is always nonsurgical.

Nonsurgical treatment may include:

• Observation​ – Your doctor may recommend simply monitoring your child with regular visits for a period of time. If he or she is toe walking out of habit, it may stop on its own.
• Physiotherapy​ – The physio will assess your child’s gait (walking pattern) as well as their overall posture and muscle strength including core stability. They will then prescribe suitable activities and/or stretches that encourage your child to walk with their heels down.
• Serial casting​ – Your doctor or physio may apply a series of short leg walking casts to help progressively stretch and lengthen the muscles and tendons in the calf and break the toe-walking habit. Serial casting is usually performed over a period of several weeks.
• Orthotics​ – Wearing an ankle-foot orthosis (AFO) can help stretch and lengthen muscles and tendons. An AFO is a plastic brace that extends up the back of the lower leg and holds the foot at a 90 degree angle. Typically, bracing is performed for a longer period of time than casting (months rather than weeks).
• Botox therapy​ – For certain patients, usually those with a neurologic abnormality that leads to increased muscle tone an injection of botulinum A toxin (Botox®) may also be given to temporarily weaken the calf muscles. This will allow the muscles to stretch more easily during casting or bracing.

 

Surgical Treatment

In toe-walking children over the age of 5, the calf muscles and Achilles tendons may be so tight that walking flat-footed is not possible. For these patients, your physio will refer your child to an Orthopaedic (bone) Doctor. The doctor may recommend a surgical procedure to lengthen the Achilles tendons. Lengthening the tendons will improve range of motion and allow better function of the foot and ankle.

The specific part of the tendon that is lengthened depends on whether or not the child’s foot can be positioned flat at the ankle with his or her knee bent. There are several techniques used to lengthen different areas of the tendon. Your doctor will talk with you about which technique is best for your child.

The procedure is usually done on an outpatient basis (no overnight stay). After the tendons are lengthened, while your child is still asleep, your doctor will place his or her legs in short leg walking casts. These are typically worn for 4 to 6 weeks.

Recovery

Physiotherapy is usually recommended after both surgical and nonsurgical treatment to help the child learn to walk flat-footed more consistently. Physiotherapy after surgery typically does not begin until the walking casts have been removed.

Outcome

Most children improve over time and are able to participate in normal activities and sports. However, studies show that some children will continue to toe walk, even after serial casting or surgery.

Here at The Children’s Physio we are highly specialised in assessing and treating children with a vast range of conditions including toe walking and gait abnormalities so if you have any questions or concerns relating to your child and their development, The Children’s Physio will be able to advise.