Toe Walking in Children

Toe Walking

Toe Walking is defined as the failure of the heel to contact the floor at the onset of stance during the gait cycle, resulting in a bilateral toe to toe gait.

Idiopathic Toe Walking (ITW), as its name implies, refers to the manifestation of this gait pattern without a known underlying pathological cause. This is a diagnosis of exclusion, in which other conditions causing an equinus gait have been ruled out.

Differential Diagnosis

In considering differential diagnosis, it is important to take into account any potential underlying neuromuscular or musculoskeletal conditions. Toe walking may be caused by Cerebral Palsy, congenital contracture of the Achilles tendon or paralytic muscular disorders such as Duchenne Muscular Dystrophy. Idiopathic Toe Walking may be associated with developmental disorders such as Autism or other myopathic or neuropathic disorders.

The majority of disorders causing toe walking can be ruled out through the history and physical examination, resulting in a diagnosis of Idiopathic Toe Walking. A child with a diagnosis of ITW will present with a normal neurological exam with respect to muscle tone, reflexes, sensation and strength. The child may or may not have a passive limitation in ankle dorsiflexion. Idiopathic Toe Walking will always exhibit bilateral and symmetrical presentation, as opposed to some other neurologic conditions which may cause unilateral or asymmetric toe walking.

Background

A study by Sobel et al revealed that the majority of child who present with Idiopathic Toe Walking had a normal birth weight, walked on time, began to toe walk immediately in their gait development, stood mostly in plantigrade (feet flat), were able to demonstrate heel-toe gait when instructed, and only toe walk intermittently.

It is theorized that ITW may be one element of a more global neurodevelopmental condition, since many of these children present with other diagnoses concomitantly. Many young children are recognized as having a toe-walking tendency when they first start to walk, which is not considered an anomaly. However, if this pattern persists beyond 2-3 years of age, it should be labeled as ITW in the absence of any other pathology. A study by Le Cras et al reported a higher incidence of ITW in males as compared to females, and that a family history of ITW often exists.

Sensory Connection

Idiopathic toe walking may be linked to hyper or hyposensitivity. Some children may not like the feeling of different surfaces on their bare feet, which cause them to rise up on their toes to avoid having the full surface of their feet contracting floor. For children who are seeking more input, toe walking increases the force of impact felt during ambulation, as the ground reaction force is distributed through a smaller surface area at the metatarsal heads.

Exam/Assessment

In order to best determine an ideal treatment protocol, a comprehensive history should be taken. Children who ambulate later or skip developmental milestones which limit weight bearing, often present with ITW later on.

  • Does the child toe walk when wearing shoes?
  • Do you notice more or less toe walking when ambulating barefoot on different surfaces?  For instance sand at beach, grass at park, hard wood floor, carpet.
  • Is the child able to achieve and maintain full range of motion at ankle?
  • Evaluate passive vs active range of motion of gastrocnemius, soleus and hamstring complex.
  • Assess the child’s overall lower extremity biomechanics from position of pelvis, knees and feet.
  • Assess child’s static vs dynamic arch formation of foot. Often times children with ITW will have weak intrinsic plantar muscles, and use toe walking to compensate.

Treatment Ideas

1.Passive Range of Motiontoe walking treatment ideasGastrocnemius (Ankle dorsiflexion/plantarflexion):  With the child lying on back or seated, hold child’s foot in hand. Apply light pressure flexing foot up towards child’s head. Once you feel resistance, hold for 10-15 seconds, alternate feet and repeat stretch.

toe walking treatment ideasHamstring (Knee flexion/extension): With the child lying on back or seated, with opposite knee bent or flat on floor, lift child’s leg with knee straight until you feel resistance. Hold for 10-15 seconds, alternate legs and repeat stretch.

2. Active Range of Motion
toe walking treatment ideas
Have child stand supported/unsupported without shoes on dynamic surface. The dyna-disc, incline wedge, and wobble board are all great tools!

toe walkingAs child shifts body weight on dyna-disc to maintain balance, the child will experience an active stretch of the affected musculature.

toe walking treatment ideasHave child walk on dynamic surface without shoes. Some great options are: the wedge ramp, foam balance beam, and tactile stepping stones! This will also help promote active stretch as well as encourage intrinsic plantar muscle activation, as child will be recruiting these smaller muscles to assist with balance.

toe walking treatment ideasAnimal walks are helpful to encourage active range of motion while still having fun! Some examples include, Bear Walk (with hands and feet on floor, knees not contacting surface).

toe walking treatment ideasCrab Walk (start in bridge position, keeping bottom off floor, moving forward or backward using hands and feet to propel).

toe walking treatment ideasFrog Jump (start in deep squat, encourage full foot contacting surface during jumps).

toe walking treatment ideasPenguin Walk (with heels contacting floor and toes up)

3. Strength 

toe walking treatment ideasIntrinsic Plantar Muscles: you can target these small muscles by picking up objects with toes or negotiating dynamic surfaces (build a pillow bridge or use tactile stepping stones).

toe walking treatment ideasAnterior Compartment Musculature: you can target these muscles by navigating seated Scooter Board in forward direction, stair climbing, and stepping over obstacles.

jumpStepping or jumping over hurdles or cones offer additional ways to activate trunk and leg musculature!

toe walking treatment ideasAbdominal Musculature:  activities which challenge core strength include seated/standing balance on dyna-disc or tilt board

toe walkingSitting on therapy ball or peanut ball shifting weight back and front, side to side will help activate abdominals and obliques.

toe walking treatmentBridging exercises are great not only for trunk strengthening, but utilizing the tactile half moon roller as seen above also incorporates arch activation of both feet!

4. Weight-Bearing Activities

toe walkingEncourage barefoot standing using a variety of textures, promote squat to stand with fun activities to facilitate weight bearing. We always love dyna-disc or tactile discs for these activities!

toe walking treatmentSquats on the foam balance pad are great for lower extremity strength, stability and weight bearing through full plantar surface of foot! 

toe walking treatment ideasUse footprint cut outs to promote alignment during obstacle course or navigating stairs.  These tactile footprints are one of my favorite therapy tools, as they have both smooth and tactile sides when that extra input is needed!

toe walkingSit to stand from low stool or cube chair with visual cues to promote alignment and natural weight shifting on full surface of foot.

toe walking bucket bridgeIncorporate ramps, inclines, stairs, or this awesome Bucket Bridge!

tactile stepping stonesLove these Stepping Stones for weight bearing with tactile input and added dynamic balance challenge!

toe walkingLunges with colored spots or footprints for helpful visual cue are great for range of motion, strength and weight bearing with heels contacting surface.

toe walkingSumo squats with tactile footprint cues, focusing on weight bearing through full foot contacting floor, knees over toes encouraging child to activate trunk musculature as they lower down into squat and rise to standing.

toe walkingClimbing up playground slide is a great way to target range of motion, strength and weight bearing! 

toe walkingA hoop ladder is great for weight bearing with focus on strengthening anterior compartment musculature and focus on motor planning!

toe walkingHop Scotch with focus on full foot weight bearing, pushing off from heel vs. toes.

5. Sensory Integration Strategies

  • Joint compressions
  • Vibratory input: The Vibrating Cushion and the Vibrating Node are both great options!
  • Encourage barefoot exploration of different surfaces (sand at beach, grass outside, rubber mat at gym, hardwood floors)
  • Use of tactile material inserts in shoe
  • Heavier shoes/high tops with ankle cup to control foot alignment
  • Ankle boots, rain boots, roller skates all encourage downward input! These are great footwear options-functional and fun!  
  • Use of auditory input like Kick Spots to encourage heel strike.
  • Custom made Grippy Socks! Check out our Heel to Toe Helper Socks tutorial here!
  • Proper shoe selection can make a big impact on toe walking as well! Learn more about What a Difference a Shoe Can Make here!

toe walking shoe ideas

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References:

  1. Le Cras S, Bouck J, Brausch S. Evidence based clinical care guideline for management of idiopathic toe walking. Cincinnati Children’s Hospital Medical Center. 2011.
  2. Sobel E, Caselli M, Velez z. Effect of persistent toe walking on ankle equinus. J Am Podiatr Med Assoc. 1997 Jan; 87(1):18-22.

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  • Thanks so much for this article! School based PT who over last 5 months has started keeping a caseload at an OP PT clinic and just eval’ed a kid with the ITW. Thanks for adding to my tx plan! I was afraid that I wouldn’t have enough activities to do LT!

  • Great organization of information. I’ve also seen several idiopathic toe walkers who had decreased registration of vestibular input, lower muscle tone and altered alignment of the rib cage and pelvis. Toe walking seems to drive their anti-gravity extension. Treatment as you noted above, but with the addition of graded vestibular input was helpful for those children. Thanks again for the info!

    • Thank you Shelley! Absolutely agree about your incorporation of vestibular input in some cases! It is such a fascinating presentation and really enjoy the troubleshooting involved!

  • Hi! I have had a few patients with idiopathic toe walking and these exercises are very helpful. I am new to the pediatric PT world so any help I can get, I take! What are good suggestions for increasing muscle length of a toe walker who actually has shortened gastrocs bilaterally? The patient I am thinking of can come down on flat feet but he is actually lacking several degrees of active DF. Thanks!

    • Hi Erin! Thank you for reaching out! The best way to increase muscle length is allowing the child to become an active participant in the stretching process! Using an incline wedge or ramp having child maintain dorsiflexion stretch as they complete fun and engaging standing activities. Standing on incline wedge while at easel coloring, playing game of catch while maintaining balance on incline, or by incorporating dorsiflexion based activities into larger obstacle course, walking up ramp, performing animal walks (penguin walk, bear walk, gorilla walk…all great dorsiflexion stretches!) You can also utilize wobble board or tilt board to encourage more active range of motion! Feel free to email me directly at info@dinopt.com to speak further! Best, Rebecca

  • Hi, I’m an adult ITW. I really want to stop (and stop wearing out my fave socks so quickly). These exercises are all for children just wondering what you’d recommend for someone who is 19 now 🙂 I’ve been toe walking my whole life (started walking at 9 months old). I can stand flat footed and touch my toes but my dorsiflexion is about 0 degrees and I can’t walk on my heels unless I cheat by pushing my butt out 😛 When I am more focused on walking I tend to just put my whole foot down and then roll onto my toes rather than rolling from heel to toes, same in shoes. In shoes I will normally walk this way most of the time but I tried just wearing shoes all day to fix my problem but when I forget about walking I still end up on my toes in shoes haha! Sorry for the life story just thought you might be able to help 🙂 Thanks!

    • Thank you for reaching out! I would definitely recommend having a Physical Therapist evaluate you at this point. They can provide specific treatment strategies, helpful exercises and activities to address your concerns. If I can help in any other way feel free to reach out directly via email at info@dinopt.com.

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