What is Toe Walking

Toe walking is a pattern of walking where a child walks on his or her tiptoes and balls of the feet, and the heels do not touch the ground. This is common in children who are just learning to walk and are age 2 and younger. Most children outgrow toe walking and begin normal heel-to-toe walking.

Your child may need to be checked or treated if:

• He or she is age 2 or older and has not outgrown toe walking.
• Toe walking causes pain or tightness in the calf muscles or the tendon that attaches the leg muscles to the back of the heel (Achilles tendon).

What are the causes?

If the cause of toe walking is not known, it is called idiopathic toe walking. Older children who continue toe walking may do so because of:

• Habit.
• Muscles and tendons becoming tight from toe walking over the years.

Medical conditions may cause toe walking due to:

• Problems in the nerves, such as cerebral palsy.
• Problems in the muscles.
• Problems in the child’s anatomy, such as:
  • Having one leg that is shorter than the other.
  • Having short muscles and tendons that do not allow the heel to touch the ground.
• Infection of muscles by a virus (viral myositis). This is rare.

What increases the risk?

Certain conditions also have a higher incidence of toe walking. Some examples are:

• Autism.
• Attention deficit hyperactivity disorder (ADHD).
• Delays in growth.

What are the signs or symptoms?

The main symptom of this condition is walking on tiptoes and on the balls of the feet. Other symptoms may vary by age:

• Younger children may also walk flat-footed when told to do so.
• Older children who develop tight muscles and tendons may have trouble doing activities like roller skating or ice skating.

How is this diagnosed?

This condition may be diagnosed based on your child’s symptoms, medical history, and physical exam.

Your child’s health care provider may also do tests to rule out other conditions. These may include:

• Nerve or muscle tests to check for sensation, reflexes, weakness, and spinal cord health.
• Gait analysis.
• Blood tests.
• Imaging tests.

How is this treated?

Treatment may not be needed for this condition. Your child may outgrow toe walking. Children ages 2–5 who continue to have toe walking may see their health care provider every 6 months (observation).

Other children may be treated with:

• Stretching. Stretching and physical therapy are done together with other treatments to create and maintain range of motion.
• Serial casting. The casts will be changed each week or every two weeks to gently increase the range of motion at your child’s ankle.
• Ankle-foot orthosis (AFO). This device fits into a regular shoe. It allows for the foot and ankle to flex and extend for nearly normal walking.
• Botulinum toxin. This is given to weaken the muscle and allow it to stretch more easily during casting or bracing.
• Surgery. Surgery may be done if other treatments have failed. After surgery, your child will be fitted with a short leg walking cast for up to six weeks.

Follow these instructions at home:

If your child has a cast:

• Do not allow your child to put pressure on any part of the cast until it is fully hardened. This may take several hours.
• Do not allow your child to stick anything inside the cast to scratch the skin. Doing that increases your child’s risk of infection.
• Check the skin around the cast every day. Tell your child’s health care provider about any concerns.
• You may put lotion on dry skin around the edges of the cast. Do not put lotion on the skin underneath the cast.
• Keep the cast clean.
• If the cast is not waterproof:
  • Do not let it get wet.
  • Cover it with a watertight covering when your child takes a bath or a shower.

If your child has an ankle-foot orthosis (AFO), also called a brace:

• Have your child wear the brace as told by your child’s health care provider. Remove it only as told by your child’s health care provider.
• Loosen the brace if your child’s fingers or toes tingle, become numb, or turn cold and blue.
• Keep the brace clean.

General instructions

• For physical therapy, help your child practice the exercises at home.
• Remind your child to get down off his or her toes when walking or standing.
• Have your child return to normal activities as told by his or her health care provider. Ask your child’s health care provider what activities are safe for your child.
• Give over-the-counter and prescription medicines only as told by your child’s health care provider.
• Do not give your child aspirin because of the association with Reye syndrome.
• Keep all follow-up visits as told by your child’s health care provider. This is important.

Contact a health care provider if your child:

• Cannot stop walking or standing on tiptoe when asked.
• Develops behavior problems.
• Develops weakness or clumsiness.
• Has leg or ankle pain.
• Has a cast or brace that feels too tight.

Get help right away if your child:

• Has trouble breathing.
• Has a cast or brace and the toes are:
  • Numb, tingling, turning blue, or cold to the touch.
  • No longer able to move.
• Has more pain or pain that does not stop after taking pain medicines.
• Had surgery and you notice fluid, blood, pus or a bad smell, warmth, redness, swelling, or pain from the surgical area.

Summary

• Toe walking refers to a condition in which a child stands or walks on the tiptoes or balls of the feet for much of the time.
• In most cases, the cause of toe walking is not known.
• Many children outgrow toe walking. Some are treated by having follow-up visits every six months. Other cases may be treated with physical therapy, casting, bracing, botulinum toxin, or surgery.
• Follow the health care provider’s instructions for caring for your child at home, including cast or brace care, and follow-up care.