In typical walking, first the heel strikes the ground, then the foot makes full contact with the ground. The final push off is through the ball of the foot.
Toe walking is when a child consistently walks on the balls of his feet, keeping the heels away from the ground throughout the full walking cycle.
Toe walking can occur for a number of different reasons in children. It is also not considered abnormal if a child walks on his toes up until the age of 2 years old.
What do I do if my child toe walks?
If you are concerned about your child’s toe walking and/or his development in general, always consult your child’s doctor. If the toe walking is concerning to your doctor, she or he will recommend physical therapy.
A physical therapist will evaluate the cause of the toe walking and then treat it accordingly.
I always recommend seeking professional medical advice when you have significant concerns about your child’s development. This post is for educational purposes only, and does not take the place of in-person assessment and treatment of a professional.
If you want more information on gross motor development in infants and young toddlers, feel free to check out this post!
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CAUSES OF TOE WALKING
Before you can treat toe walking, it is best to determine the cause.
1. Is it an idiopathic cause?
When the reason behind the toe walking is unknown, it is called idiopathic toe walking. In such cases, a medical reason behind the toe walking cannot be determined.
Whether or not to treat idiopathic toe walking and how to treat it is decided on a case by case basis.
2. Is it caused by weakness?
Toe walking can result if the muscles on the front of the ankle and shin are too weak. This weakness prevents a child from bringing his toes up towards his shin in order to have a heel strike when walking.
A child might also or instead have weakness in the muscles in his feet that support the arches of his feet. A compensation for this unsupported foot arch is toe walking.
Lastly, core weakness and hip weakness can lead to toe walking. By toe walking, a child over-compensate for a weak core by making his body rigid.
There are certain medical conditions that can result in weakness of these muscles. Muscular Dystrophy is a genetic condition that is characterized by progressive weakness. Sometimes, those who have Muscular Dystrophy once had a normal walking pattern, but adapt to toe walking as they become weaker.
Also, for younger children, make sure to avoid toys and equipment that bring a child up on his toes. This can lead to muscle imbalances - the muscles in front of the ankles are underdeveloped, while the calf muscles are overdeveloped. Check out this post for more info!
Toe walking can also be the default walking pattern when a child cannot bend his ankles enough to get his feet flat on the ground. A child will walk up on his toes because his muscles and/or connective tissues are tight.
A common cause of ankle range of motion restriction is a shortened achilles tendon. Hamstring tightness on the back of the thighs can also lead to toe walking.
Cerebral palsy is a diagnosis that commonly results in some level of toe walking due to shortened achilles tendons, tight hamstrings, and/or increased tone of the muscles.
4. Is it sensory related?
Either increased or decreased sensory processing can also result in toe walking. Your senses include: sight, smell, hear, taste, and touch. The are other aspects of the sensory system that contribute to body awareness.
Some children have an increased sensitivity to sensory input. They might resort to toe walking because the full contact of feet on the floor is overwhelming to their sensory systems.
Other children have a decreased sensitivity to sensory input, and therefore seek out more sensory input. Toe walking can increase the intensity of sensation in the balls of the feet since all of the weight bearing is isolated to that area.
Sometimes when it is sensory related, the toe walking appears or disappears when wearing shoes versus when barefoot. A child might also toe walk on some surfaces (i.e. grass or sand) but not on others (i.e. laminate).
ACTIVITIES TO IMPROVE TOE WALKING
Below are many of the exercises and activities utilized in a physical therapy setting to address toe walking. Many of them can also easily be practiced in a home environment.
1. Ankle Stretch
The goal here would be to stretch the toes towards the shin bone to allow a child to have a heel strike and to maintain feet flat on the ground when walking.
2. Hamstring Stretch
Hamstrings are large muscles that cross both the hip joint and the knee joint. Tightness here can drastically affect standing and walking posture. Sitting on the ground, with legs straight, have a child reach towards his feet to achieve this stretch.
Have a child lay on the floor with his knees bent. Cue him to elevate his hips from the floor, bringing his belly button towards the ceiling for core strengthening.
This exercise is great for core and hip strengthening. Depending on the depth of the squat, it will also activate muscles on the front of the ankle and produce an ankle stretch.
5. “Crab Walking”
This is an ideal core strengthening activity but it can also target ankle strengthening. An added challenge would be to keep the toes off of the floor.
6. “Frog Jump”
Hopping around like a frog achieves a good ankle stretch and full foot contact with the floor.
7. Single Leg Hop
Single leg hopping is another strategy for ankle stretching and full foot contact with the floor. The balance component of hopping on one leg also works the small muscles in the foot.
8. Walk with Toes Up
Encourage a child to walk around on his heels to increase the strength of the muscles that cross the front of the ankle.
9. Stool or Scooter Walking
Depending on the age and height of the child, have him sit on a rolling stool or a scooter board. These scooter boards are so much fun! Then have the child move himself forward using his heels on the ground. This will strengthen the ankle but also the hamstrings, which contribute to hip/core strength.
10. Standing on Uneven Surfaces
Have a child stand on an uneven surface like a pillow, a piece of foam, a BOSU ball or a dyna disc. This will encourage both stretching and strengthening of small muscles in the foot, that contribute to the arch of the foot.
11. Gather Towel with Toes
Place a towel under a child’s foot and cue him to bunch the towel up using his toes and feet. This is an exercise to strengthen the small muscles in the foot.
12. Desensitize Feet
If the child has an increased sensitivity to sensory input, it might help to habituate the child to some of these sensations.
This can include brushing the bottoms of the feet with different textured items, like a wash cloth, a brush, a sponge, etc. Another technique is for a child to walk around barefoot on a variety of different surfaces like, hard wood, carpet, grass, sand, etc.
13. Shoes with Arch Support
For a child who has weakness and instability in his feet, a shoe with good arch support can help improve toe walking. A supportive shoe will help align the foot in a more stable position.
Shoe brands on Amazon that generally provide good arch support for children include, Keen and New Balance.
OTHER PHYSICAL THERAPY AND MEDICAL INTERVENTIONS
If the above interventions are not successful with treating toe walking, or if there is a severe structural restriction to typical walking, other techniques might be recommended.
14. Leg braces and Ankle-Foot Orthoses
A doctor or physical therapist might recommend supportive leg braces if conservative approaches alone are not working. Such braces can help with weakness, alignment issues, or with children that have increased tone of their muscles.
15. Serial Casting
This approach is sometimes used when there is a range of motion restriction at the ankle, causing toe walking. A series of casts are applied over time to encourage progressively greater flexibility at the ankle joint.
Botox can be used in children that have increased tone or spasticity that negatively impacts their mobility. In terms of toe walking, this can be used to relax the affected muscles and allow for a more typical walking pattern.
Lastly, surgery can sometimes be recommended for achilles tendon lengthening if stretching alone will not improve range of motion restrictions.
THINGS TO REMEMBER
So that was a lot! And if you’re reading this because your child is toe walking, then you might already be overwhelmed. Here are some key take aways for now, and you can always come back to this article later...
1. Make sure you reach out and get that support that you and your child need.
2. Always seek professional medical advice if you are at all concerned about the development of your child.
3. Remember that toe walking is not considered problematic prior to 2 years of age, in most cases.
4. The cause of the toe walking must first be determined in order to determine the best treatment.
5. Lastly, keep in mind that there are lots of great treatment options and talented physical therapists out there that are ready to help you and your child!