When is toe walking in children a concern?

Is toe walking normal?

Many toddlers walk on their toes some of the time when they are learning to walk. Most develop a heel-to-toe walking pattern by around age 2 to 3 1.

When a child continues to walk on their toes without an identifiable cause, it is called idiopathic toe walking. The child can usually stand with the heels down and walk flat-footed when asked.

How common is idiopathic toe walking, and does it resolve?

In a population-based study of 1,401 healthy Swedish children assessed at 5.5 years, about 5 per cent (63 children) had been toe walkers at some point 1. By age 10, 79 per cent of these children had stopped toe walking spontaneously, without treatment 1.

Idiopathic toe walking did not lead to tightness of the calf muscles in that study. However, a subgroup of children had early tightness of the ankle and should not be regarded as idiopathic toe walkers 1.

When is toe walking a concern?

Assessment is recommended if a child cannot put the heels flat on the ground, has tight calf muscles, toe walks on one side only, has stiffness, frequent falls or clumsiness, or if toe walking starts after a period of normal walking.

Toe walking together with delays in speech, social communication or motor development, loss of previously acquired skills or muscle weakness also needs evaluation.

What conditions can cause toe walking?

Toe walking can be associated with mild cerebral palsy, muscular dystrophy, autism spectrum conditions, developmental coordination disorder, nerve problems and a short Achilles tendon present from early childhood.

In the Swedish study, four of the children still toe walking at age 10 had some neurodevelopmental condition, suggesting that persistent toe walking warrants a careful developmental assessment 1.

How is toe walking assessed?

A doctor or physiotherapist checks the ankle's range of movement, muscle tone and strength, reflexes, walking pattern, balance and development. They ask about birth history, family history and milestones.

Further tests, such as blood tests for muscle enzymes, nerve studies or referral to a neurologist, are arranged if there are signs of an underlying condition.

What treatments are used?

When the ankle moves normally and there are no other concerns, observation is often appropriate given the tendency to resolve. Calf stretching, strengthening and gait practice may be used.

If the calf and Achilles tendon are tight, options include serial casting, night splints, ankle-foot orthoses, botulinum toxin injections in some cases and, for persistent fixed tightness, surgery to lengthen the tendon. The choice depends on age, severity and any underlying condition.

How is serial casting used for toe walking?

Serial casting is sometimes used when the calf muscles and Achilles tendon are tight enough to stop the heel from reaching the ground. A series of below-knee casts is applied, each one holding the ankle at a slightly greater stretch, usually changed at regular intervals over several weeks.

Children can usually walk in the casts. Afterwards, a stretching and strengthening programme, and sometimes night splints or orthoses, help maintain the improvement. Casting is chosen after assessment and is not needed for children whose ankles already move normally.

What can parents do?

Encourage active play, barefoot walking on varied surfaces, squatting games and activities that bring the heels down, such as walking up slopes.

Keep a note of how often your child toe walks and any other developmental concerns to share with the clinician.

Frequently asked questions