Toe Walking In Children

Toe walking is a gait abnormality characterized by an absence of normal heel-to-floor contact (heel strike) by both feet during gait, with the forefoot engaging in the majority of floor contact throughout the gait cycle. Toe walking has multiple etiologies, ranging from idiosyncratic habit to profound neuromuscular disease.

Critical to the management of toe walking is the exclusion of neurologic or muscular diseases as a cause of the perceived gait abnormality. Treatment depends on the patient’s age and severity of the gait abnormality. Specific treatment options range from simple observation to surgical lengthening of muscles or tendons in the lower extremity.

Most children begin walking at 12 to 14 months with their feet flat on the ground. However, there are some children who begin walking on their tip toes instead. This pattern normally disappears within 3 to 6 months of learning how to walk. It almost always is completely gone by the end of the third year.

Idiopathic toe walking is when a child continues to walk on his tip toes beyond 3 years of age. He will often stand with his feet flat on the ground, but when walking or running will prefer to be on his toes. If your child does not outgrow tip toe walking by 3 years of age, take him to see a health care professional.

Symptoms of toe walking in children include:

• walk on tip toes on both sides
• are constantly balancing on their toes
• are physically able to keep up with other children their age
• walk with straight knees
• will often be able to stand with their feet flat on the ground
• often have a family history of toe walking
• Walks on her toes most of the time
• Has stiff muscles
• Is uncoordinated
• Walks awkwardly, stumbles, or has a waddling gait
• Has fine motor skills that don't seem to be developing normally (for example, she can't button her shirt)
• Seems as though she can't bear her weight on a flat foot
• Loses motor skills she already had

Various causes of toe walking in children include:

• Both central and peripheral neurologic disorders (eg, tethered cord, diastematomyelia, spina bifida, cerebral palsy),
• Muscular disorders (eg, congenital muscular dystrophy),
• Anatomic disorders such as limb length discrepancy.
• Some rarer causes of toe walking have also been reported in the literature, such as acute toe walking secondary to viral myositis.

The most common cause of toe walking is idiopathic, meaning no identifiable pathologic process exists to explain the perceived gait abnormality. Idiopathic toe walking (ITW), first described by Hall in 1967 as “habitual toe walking” and “congenital short Achilles tendon,” is a diagnosis of exclusion.

ITW is best defined as bilateral toe walking with or without Achilles tendon contracture in a child older than age 2 years in the absence of other etiologies.

Making a diagnosis of toe walking in children is done by performing several tests.

A doctor will typically evaluate whether there is bilateral (both legs) toe walking, what the child's range of motion is (how far they can flex their feet) and perform a basic neurological exam.

Treatment will depend on the cause of the condition. An assessment of your child's brain function and motor development is necessary to help your child's doctor figure out the best course of treatment.

Early intervention is critical because physical therapy or surgery can improve motor skills and muscle strength, and prevent damage to the muscles that affect joint movement.

Although no formal imaging studies are required for a routine evaluation of toe walking, studies discussed below may be used to gain more insight into the etiology of toe walking:

• Standing anteroposterior (AP), lateral, and oblique radiographs of the feet
• These radiographs are used to more objectively assess ankle equinus and rule out a possible bony foot or ankle abnormality as a cause for the toe walking.
• Posteroanterior (PA) and lateral radiographs of the spine
• In a patient with muscle spasticity that is not secondary to cerebral palsy or in a patient with isolated lower extremity weakness, PA and lateral radiographs of the thoracolumbar spine are indicated to rule out bony abnormalities that may suggest a spinal cord abnormality. Large posterior element defects and a widened distance between pedicles might indicate an intraspinal anomaly.
• MRI of the spinal cord/brain: If the plain radiographic findings are positive or if clinical suspicion for a focal neurologic abnormality is high, an MRI of the spinal cord and/or brain should be obtained as a definitive screen for the possibility of a focal pathologic process in the central nervous system. MRIs of the spine in younger patients invariably require sedation services to allow a good resolution study.

• Gait Analysis: Gait analysis can be particularly helpful in a patient with a spastic etiology to toe walking, as it helps to separate the multiple joint and muscle contributors to the observed gait.
• Serum creatine phosphokinase (CPK): CPK levels are markedly elevated in Duchenne muscular dystrophy.
• Muscle biopsy: Muscle biopsy is becoming less common as genetic tests can increasingly offer similar information without the associated procedural morbidity.
• Electromyography (EMG): EMG can be performed if the family history and/or clinical symptoms are suggestive of hereditary sensorimotor neuropathies.

Several treatment methods exist for toe walking in children.

Children who walk on their toes can develop tight calf muscles on the backs of their legs and have decreased movement of their ankles. In addition, the muscles on the front of their legs may become weak.

If there is tightness and weakness, your child will have difficulty walking on his heels. Early identification of toe walking can help lead to the prevention of these muscle problems.

If your child has idiopathic toe walking, a daily home exercise program can be very helpful. The goal is to stretch the calf muscles and strengthen the muscles on the front of the legs. This will help your child to be able to successfully walk with a heel-to-toe pattern.

If your child’s calf muscles are tight, or ankle motion is limited, you will be shown stretches to do at home with him. These stretches should be followed with activities to help him use his muscles in their new lengthened position.

These exercises will be necessary and beneficial as long as your child demonstrates a tip toe walking pattern. The exercises will vary with his age.

Stretches and strengthening exercises for children under 6 years of age

Calf stretch:

• Have your child lie on his back on a comfortable surface such as a firm bed.
• With his knee straight and leg supported on the bed, bring your child’s foot upwards, toward his head, bending his ankle.
• Hold the stretch at the end of the movement (that is, as far as your child’s range of motion will permit) for 15 to 30 seconds. This should not be painful for your child.
• Bring your child’s foot back to a normal position. Repeat the exercise 10 times on each leg, daily.

Achilles tendon stretch:

• Have your child lie on his back on a comfortable surface such as a firm bed.
• With his knee bent, bring your child’s foot upwards, toward his head, bending his ankle.
• Hold the stretch at the end of the movement (that is, as far as your child’s range of motion will permit) for 15 to 30 seconds. This should not be painful for your child.
• Bring your child’s foot back to a normal position. Repeat the exercise 10 times on each leg, daily.

Sit to stand:

• Have your child sit on a children’s sized chair or stool.
• Place your hands below his knees, providing a moderate, constant pressure downwards as a cue to
• Keep his heels on the floor.
• Have your child practice standing up while keeping his heels on the ground.
• Make this exercise fun by playing a game of high five, blowing bubbles, reaching for objects, working in front of a mirror, or singing songs.

Exercises suitable for children ages 6 years and up:

Calf Stretch:

• Have your child stand approximately two feet from a wall. Place both of his hands at shoulder height against the wall.
• With his right knee straight, have him step towards the wall with the left foot. He should lean in until a stretch is felt in the back of the right calf. Make sure he keeps the heel of the right foot on the ground.
• Hold the stretch for 15 to 30 seconds.
• Repeat the exercise 10 times on each leg, daily.

Other exercises include:

• Marching on the spot. Have your child bring his knees up high and then land with a flat foot.
• Walking uphill.
• Walking on uneven surfaces such as in a playground or sand.
• Walking on the heels only. Keep the toes off the ground at all times.
• Practicing squats. With feet flat on the floor, hip width apart, have your child slowly lower his body all the way to the floor by bending at his knees and hips but keeping his chest upright.

Shoes for your child. Wearing shoes may not correct toe walking. However, appropriate foot wear can help your child bring his heels further down.

When selecting shoes for your child, keep in mind the following criteria:

• Choose a high cut shoe with a wide sole which provides good foot support.
• The shoe should be rigid or firm, not flexible in the middle section.
• The back of the heel should be firm.

Other treatments

Idiopathic toe walking in children is not a serious condition. It often resolves spontaneously and does not cause the child significant problems apart from the cosmetic appearance.

Normally, your child will not need surgery. In addition to stretching and strengthening, treatments may include repeated casting of feet and ankles, bracing devices, or a combination of the two.

More recently, the injection of Botulinum Toxin A (Botox) has been used to weaken the calf muscles, thus preventing tip toe walking. You can discuss these treatment options with your physician.

It is important to understand that even though your child may achieve short-term improvement in muscle length and ankle range of motion, these treatments may not always guarantee a normal heel-to-toe walking pattern.

The following shoes help to preventtoe walking in children:

• Flat shoes: Avoid putting your child in wedge shoes or shoes with any sort of heel. These types of shoes place the foot in a position where the calf muscles are in a shortened position, which can result in them becoming tighter and facilitate more toe walking.
• Squeaky shoes: There are some footwear brands that design shoes with squeakers in the heels. Every time your child walks down on their heels, they will hear the squeak.
• Shoes with high backs: There are some gym shoes that are designed to have a higher backing compared to other shoes. If a child is wearing these shoes and is walking on his or her toes, the shoe back will press up against the Achilles tendon, which can be uncomfortable for the child. Since these shoes make it uncomfortable for a child to toe walk, these shoes help facilitate walking on flat feet.
• Light up shoes: Shoes that light up often have the lights towards the back of the shoe by the heel. If a child appropriately walks with feet flat on the ground, the lights will light up more than if the child walks up on toes.

While all of these options can be helpful in discouraging toe walking, your child may continue to walk on his or her toes. If your child toe walks the majority of the time and is over 2 years old, it would be beneficial to speak with your pediatrician and physical therapist to determine if further intervention is needed.

There are several risks and complications associated with toe walking in children.

For some children, toe walking may be one of the first signs of cerebral palsy, muscular dystrophy or another muscular disorder. It may also be a sign of a sensory integration disorder that will need further evaluation by a pediatric occupational therapist.

Kids who spend a lot of time on their toes can develop stiffness, tightening, and pain in their Achilles tendon, which can be treated with physical therapy and stretching exercises. Rarely surgery may be required (usually after age 6) if the toe walking is the result of (or results in) tendon stiffness.

A lot of children feel the social stigma attached with the disorder which requires psychiatric counseling.