This is a guest post by Shannon Kinne, a student physical therapist assistant who is on her last clinical rotation with me. Enjoy her blog on Toe Walking and comment below on your thoughts and ideas about Toe Walking. A special thanks goes out to her adorable niece, Madison! Thanks for being our model!
Toe walking in children can be normal as a child is developing from infant to toddler. Developing children up through approximately age three can have the inability to strike first with their heel during their gait cycle (medical term for “walking”) as they learn to walk. You may have seen older children still walking on their toes. There is not one solid answer for this; therefore, it is important to look into the reasons that may contribute to toe-walking.
It is important to know that even if a child continues to keep walking on their toes as they get older, it does not mean they have an underlying serious condition. Children older than three who do not show signs of neurological, orthopedic or psychiatric disorders may walk on their toes due to generalized stiffness of connective tissue, muscle weakness, nerve related issues or a mixture of them. The main cause for concern in these cases would be muscle soreness, tightening and pain in the calf and in their Achilles tendon. Constant shortening of the Achilles tendon and/or gastrocnemius and soleus muscles (calf muscles) could turn into contractures (shortening and hardening of a muscle) if left untreated.
Treatments for these types of conditions can depend on the severity of the problem. Physical therapy and even at home stretching can help to re-train a muscle and assist them into a more normal walking pattern. Some fun stretches for kids could be animal walks. For example; ask your child to do a “bear walk” across the room by coming up onto all four extremities, and attempting to keep their heels pushed down towards the floor as they walk. You can see the stretch they will achieve as this also puts the child’s foot into a more flexed position. In more severe cases, a child may require casting or splinting to keep the ankle in a more neutral position allowing a constant stretch and re-training of the muscles. Surgery has also been an option for some children when lengthening of the tendons and muscles are required.
In some cases, toe walking can be the result of a neurological disorder. Often they continue to have full range of motion in their ankle; however, they may be experiencing some form of developmental delay. There seems to be a high incidence of toe walking with children who may have cognitive or mental disorders. Children with autism often experience sensory issues in which the brain does not receive feedback telling the body which motion they are performing or position they are in. Cerebral Palsy and Muscular Dystrophy are other known neurological disorders to cause a child to walk on their toes. Cerebral palsy is caused by a brain injury or brain abnormality which can affect the body’s control of muscle tone, strength and coordination. Increased tone or spasticity in a muscle does not allow relaxation of the extremities which can cause the child to come up onto their toes. With muscular dystrophy, this rare disease causes muscle fibers to break down and muscle weakness which can attribute to the toe walking, and can be one of the early signs and symptoms as they begin to walk.
How do you think toe walking can affect a child in the long run? What ideas do you have to incorporate “fun play” into the process of rehabilitation?
References:
Engelbert R, Gorter J, Uiterwaal C, van de Putte E, Helders P. Idiopathic toe-walking in children, adolescents and young adults: a matter of local or generalised stiffness?. BMC Musculoskeletal Disorders [serial online]. March 21, 2011;12:61.
Anderson, J. M. (2011). Idiopathic Toe Walking. Cincinnati Childrens Hospital Medical Center, 1-17.
Childrens Hospital of Wisconsin. (2014). Muscular Dystrophy. Childrens Hospital of Wisconsin.
Nair, D. (2013). Toe-Walking in Children Could be Sign of Developmental Delay. Mental Health: Counsel & Heal.
Stephen M Edelson, P. (2014). Toe Walking. Autism Research Institute.
The purpose of this blog is to provide resources for parents who want to carry over therapy activities with their child at home. The information provided here does not replace therapy or medical care provided by a qualified therapist or medical professional.
These activities are safe for most children. However, some activities or materials may be inadvisable for children who have certain allergies or medical conditions. It is recommended that you consult your child’s medical provider or therapist before engaging in the activities you have selected.
Tricia McNeil 
Other treatment ideas include prism glasses as the child may not be seeing the world as we see it. Working on balance on uneven surfaces such as a bosu ball or couch cushion providing more input into the heel may also help. Children may get AFOS to also work to keep their whole foot on the ground. The tightening of the muscles in the calf and ankle would be the biggest issue in the long run I think. This could limit other movements possibly such as jumping and running.
Great ideas Sara! Many kids who toe walk have no sense of standing balance when they are flat footed or when they shift their weight back. Practicing their balance skills while weight shifting posteriorly (back on the heels) will help them feel more comfortable on their heels and ultimately flat footed. The AFOs are also used to help align the feet better. In my experience, many kiddos who heel walk actually have flat feet (low or no arches) when they are off of their heels. The AFOs (braces) help to align their feet better to give more support. Thanks for your input!
Good article! Making rehab fun is always the key in making it effective for kids. For toe-walkers I would heat the calf muscles, then massage and stretch them first before treatment. Then I always had them try different walks like heel walking, walking in a squat position, side shuffling, stomping, walking uphill on a treadmill, etc. We would also do a lot of obstacle courses. Obviously it always depends on the severity of the toe-walking and what activities to try.
Do you have any other recommendations for parents to do at home for in between sessions?
Great question! In addition to some of the other great comments, you can add different types of animal walks as there are so many different ways to make it fun for example; “penguin walks” simply by asking them to walk across the room on their heels or “duck walks” while having them do a deep knee bend (in a squat) and walk with their hands behind their back. Other ideas could be to simply walk up and down a driveway, hill or ramp to promote that heel strike to the ground. Playground equipment at the park is always a good choice as they can climb up ladders, use the stairs, and walk across wobble bridges if they are able to. While you’re sitting on the couch together, try doing some light sustained stretches while bringing the toes back and holding for about 15 to 30 seconds at a time. Hope this helped with some other ideas. Thanks for the question!