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.
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.
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.
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.
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.
1.Passive Range of MotionGastrocnemius (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.
Hamstring (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.
As child shifts body weight on dyna-disc to maintain balance, the child will experience an active stretch of the affected musculature.
Have 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.
Animal 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).
Frog Jump (start in deep squat, encourage full foot contacting surface during jumps).
Penguin Walk (with heels contacting floor and toes up)
Intrinsic 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).
Anterior Compartment Musculature: we can promote active dorsiflexion using soft bean bags, allowing child to flex ankle upward for both strengthening of anterior musculature of leg as well as active range of motion of ankle and foot musculature.
Bean bag walks promote prolonged ankle dorsiflexion and encourage active heel contact with floor.
Navigating seated Scooter Board helps to engage anterior compartment musculature and provide additional weight bearing element to heel as child propels forward.
Floor ladder with colored spots for additional visual cues to promote both eccentric and concentric lower extremity strength, promoting hip & knee flexion, & ankle dorsiflexion.Stepping or jumping over hurdles or cones offer additional ways to activate trunk and leg musculature!
Bridging 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
Squats on the foam balance pad are great for lower extremity strength, stability and weight bearing through full plantar surface of foot!
Use 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!
Sit to stand from low stool or cube chair with visual cues to promote alignment and natural weight shifting on full surface of foot.
Incorporate ramps, inclines, stairs, or this awesome Bucket Bridge!
Love these Stepping Stones for weight bearing with tactile input and added dynamic balance challenge!
Sumo 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.
Wall sits with incline wedge, for weight bearing with active stretch through lower extremity musculature as well as engagement of trunk musculature!
Climbing up playground slide is a great way to target range of motion, strength and weight bearing!
A hoop ladder is great for weight bearing with focus on strengthening anterior compartment musculature and focus on motor planning!
Hop 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!
Learn more about Dinosaur Physical Therapy!
- 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.
- 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.